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Stroke Prevention in Middle-Aged and Older Arab Immigrant Women: Emphasizing Strengths
and Identifying Challenges.
by
Jordana M. Salma
A thesis submitted in partial fulfillment of the requirements for the degree of
Doctor of Philosophy
Faculty of Nursing
University of Alberta
© Jordana M. Salma, 2017
ii
Abstract
Arab immigrants constitute a minority group that is increasing in Canada. Minimal
literature exists on Arab immigrant women’s experiences of ageing while managing health
concerns. The evidence suggests that stroke risk factors are on the rise in this population with a
lack of supportive resources to address stroke prevention. The aim of the dissertation research
project was to better understand middle-aged and older Arab immigrant women’s experiences of
engaging in health-promoting practices in the context of stroke prevention. A life course
perspective that incorporates elements from feminist and transnational theory was used to look at
the social, economic, personal, and structural influences that shape women’s experiences across
different migration contexts. Sixteen women from the Levant region living in an urban Canadian
center were recruited from a mosque and an Islamic community center. An interpretive
descriptive approach was used by a bilingual researcher to guide data collection and analysis in
the Arabic language. Data collection involved administering health and demographic
questionnaires and conducting semi-structured interviews. Audiotaped interviews were
transcribed verbatim, followed by thematic data analysis. Final themes and exemplars were
translated into English by a certified translator.
The dissertation is composed of five chapters: an introductory chapter, three core paper
chapters and a concluding chapter. Chapter one and five, the introduction and conclusion, present
an overview of the study process and theoretical approach, implications for research, education,
and practice, and study limitations and dissemination goals. Chapter two is a reflection on ethical
tensions encountered in the research process, with a focus on issues of identity, social
positioning, and discourses about Arab Muslim communities. Study findings are discussed in
chapters three and four to include a transnational life course analysis of social dimensions of
iii
health and an intersectional analysis of women’s experiences with stroke prevention. In chapter
three social dimensions of health are addressed in relation to social roles, social support, and
transnational connections. Women’s stories extend beyond specific practices of stroke
prevention to include experiences of maintaining physical, mental, and emotional health across
the life course. Chapter four focuses on women’s experiences with stroke prevention in relation
to expanding health literacy, making healthy lifestyle choices, and managing chronic illnesses.
An intersectionality lens is used to highlight structural barriers and the discourses that reinforce
these barriers within the Canadian context. A fourth paper is included in the appendices as a
work in progress that describes considerations and challenges for data collection and analysis in
research with Arab immigrant populations. Overall the dissertation presents methodological and
ethical approaches used in the research process, recounts narratives of Arab immigrant women’s
health concerns while ageing in Canada, and draws from these narratives to identify multi-level,
multi-dimensional influences on Arab immigrant women’s health.
iv
Preface
This thesis is an original work by Jordana Salma. The dissertation research component received
research ethics approval from the University of Alberta Research Ethics Board, “Stroke
Secondary Prevention: Facilitators and Barriers in Middle-Aged and Older Arab Immigrant
Women”, no. Pro00044841, February 26, 2014.
Chapter two: “A Bicultural Researcher’s Reflections on Ethical Research Practices with Muslim
Immigrant Women: Merging Boundaries and Challenging Binaries.” is accepted for publication
in Advances in Nursing Science. Authorship: Jordana Salma, Linda Ogilvie, Norah Keating, &
Kathleen F. Hunter. I was solely responsible for data collection, analysis, and manuscript
composition. The three co-authors contributed to multiple revisions of this paper, including
development and re-structuring of concepts.
v
Dedication
To my mother, Linda, who supported me in countless ways along this journey…
Me: Mom I have to study for an exam tomorrow.
My mother: I know you will do great, let’s spend the day at the beach instead.
Me: Okay mom.
vi
Acknowledgements
I am grateful to all the women who so graciously supported and participated in this study.
I feel privileged to have had the opportunity to share your stories.
To Linda Ogilvie, my supervisor, you have been a mentor from the first day I took one of
your graduate classes to this final leg of the journey, completing a dissertation with three young
children. You gave me the time and space to do this doctorate my way, with many mistakes on
my part that have constituted valuable lessons. I learnt from you that humility and high
expectations can pair well together; something I try to model in my teaching. I will miss our
meetings over a cup of tea to discuss my research progress and talk about the place of nursing in
the world. Thank you.
To Norah Keating and Kathleen Hunter, my heartfelt gratitude for your patience and
kindness on this journey. I know this doctorate took longer than you would have expected and
involved more maternity leaves than even I could have imagined. Throughout you have provided
encouragement and challenged me to bring my best abilities forward.
To my husband Abed, who has only ever known his wife as a graduate student, I am so
grateful to have shared this journey with you. Your strength, patience, and love have gotten me
through the darkest of times. My children, Maram, Adam, and Bilal, thank you for putting up
with a tired mother who let you watch more television and eat more cereal than is good for you.
You have trained me to be an efficient writer and a thinker on the go. I owe the completion of
this doctorate to you.
To my sister Jenan, my brother Hamoudi, and my sister-in-law Malak, thank you for
always reminding me to smile, chill, and enjoy life a little. To those two adorable new family
vii
additions, Monroe and Fatima, your smiles have kept me positive through the last writing
marathon for this dissertation. Aunt Nancy and Uncle Dwayne, I am grateful for your support
during my transition to Canada and for the ongoing love throughout this journey.
I thank my grandmother Souhaila and my mother-in-law Layla for showing me how to be
a strong and proud Muslim woman. You will always be the voices in my head that remind me to
pray, to be honest, and to stay strong. Finally, my love and gratitude goes to my father, Maher,
who ignited the spark that set me on this journey of learning. Your love of reading and writing
was contagious at a young age, leading me to always ask and try to answer difficult questions.
viii
Contents
Chapter One ................................................................................................................................................ 1
The Origins of a Question ......................................................................................................................... 1
Study Question .......................................................................................................................................... 3
Study Objectives ....................................................................................................................................... 3
Definition of Terms ................................................................................................................................... 4
Study Significance .................................................................................................................................... 6
Study Methodology ................................................................................................................................... 7
Conceptual Framework: An Emergent Process ...................................................................................... 10
References ............................................................................................................................................... 13
Chapter Two .............................................................................................................................................. 21
Chapter Two................................................................................................................................................ 22
A Bicultural Researcher’s Reflections on Ethical Research Practices with Muslim Immigrant Women:
Merging Boundaries and Challenging Binaries. ..................................................................................... 22
Merging Boundaries: Islam at the Center of Feminism .......................................................................... 24
Making Sense of the Many Shades of Feminism ................................................................................ 24
Re-imagining Islamic and Feminist Convergence .............................................................................. 25
Moving towards an Islamic Feminist Ethics ....................................................................................... 27
Challenging Binaries: Identities, Values, and Power Positions .............................................................. 28
Embracing Complexity in the Research Context .................................................................................... 31
Reconciliation within Ethically Important Moments .............................................................................. 32
Navigating Identities to Ensure Respectful Interactions ..................................................................... 32
Valuing Situated Knowledge in the Pursuit of Justice ........................................................................ 35
Recognizing Agency in Concerns for Welfare ................................................................................... 38
Conclusion: Reflecting on Tensions and Imagining Possibilities ........................................................... 42
References ............................................................................................................................................... 44
Chapter Three ........................................................................................................................................... 50
Chapter Three.............................................................................................................................................. 51
Social Dimensions of Health across the Life Course: Barriers and Facilitators to Engaging in Health-
Promoting Practices in Middle-Aged and Older Arab Immigrant Women. ........................................... 51
Theoretical Approach .............................................................................................................................. 52
Research Design...................................................................................................................................... 53
Sample................................................................................................................................................. 54
ix
Data Collection ................................................................................................................................... 54
Data Analysis ...................................................................................................................................... 55
Social Dimensions of Health across the Life Course .............................................................................. 56
The Necessity of Staying Strong ......................................................................................................... 57
Caring for Self while Caring for Others .............................................................................................. 58
Double Jeopardy of Chronic Illnesses and Loneliness ....................................................................... 60
Inadequate Support despite Large Social Networks ........................................................................... 61
Triple Ingredients for Empowerment: Faith, Language, and Driving ................................................. 63
Discussion ............................................................................................................................................... 65
Maintaining Transnational Connections across the Life Course ........................................................ 66
Availability of Social Support in the Post-Migration Context ............................................................ 67
Conclusion: Limitations and Implications .............................................................................................. 69
References ................................................................................................................................................... 71
Chapter Four ............................................................................................................................................. 77
Chapter Four ............................................................................................................................................... 78
An Intersectional Exploration: Experiences of Stroke Prevention in Middle-Aged and Older Arab
Muslim Immigrant Women in Canada. ................................................................................................... 78
Theoretical Approach .............................................................................................................................. 79
Research Design...................................................................................................................................... 80
Research Methodology ....................................................................................................................... 80
Sample................................................................................................................................................. 80
Data Collection ................................................................................................................................... 82
Data Analysis ...................................................................................................................................... 82
Experiences of Engaging in Stroke Prevention Strategies ...................................................................... 83
Weaving a Narrative to Explain Chronic Illnesses ............................................................................. 83
Pursuing Knowledge in the Dark ........................................................................................................ 84
Negotiating Pill Taking and Treatment Options ................................................................................. 86
Making an Effort to Eat Healthy and be Active .................................................................................. 88
Navigating Access to Health Resources ............................................................................................. 89
Discussion ............................................................................................................................................... 90
A Tug and Push Dynamic: Narratives of Exercising Personal Agency .............................................. 91
Fallacies of Representation: Moving from Narrative to Discourse..................................................... 92
Conclusion: Limitations and Implications .............................................................................................. 93
References ............................................................................................................................................... 95
Chapter Five ............................................................................................................................................ 101
x
Emphasizing Strengths and Identifying Challenges ............................................................................. 101
Towards a Life Course Interpretive Framework: Guiding Concepts .................................................... 105
Implications for Future Practice, Policy, and Research ........................................................................ 107
Practice Considerations ..................................................................................................................... 107
Policy Considerations ....................................................................................................................... 108
Research Considerations ................................................................................................................... 109
Study Limitation and Strengths ............................................................................................................ 110
Areas for Future Research .................................................................................................................... 112
Study Dissemination Process ................................................................................................................ 114
Final Thoughts ...................................................................................................................................... 115
References ............................................................................................................................................. 117
Bibliography ............................................................................................................................................ 123
Appendix A: Recruitment Posters ........................................................................................................... 157
Appendix B: Sociodemographic Questionnaire ....................................................................................... 158
Appendix C: Interview Guide .................................................................................................................. 160
Appendix D: Information Letter and Consent Form ................................................................................ 162
Appendix E: Confidentiality Agreement ................................................................................................. 164
Appendix F: Ensuring Rigor in the Research Process ............................................................................. 165
xi
List of Tables
Table 1: Health Information………………………………………………………………82
Table 2: Socio-Demographic Information………………………………………………..83
xii
List of Figures
Figure 1: Transcription and Translation Process………………………………..Appendix F
1
Chapter One
The Origins of a Question
A global increase in aging populations, especially evident in Western nations, has
propelled the issue of healthy aging to the forefront of policy and research agendas (Marmot,
2005). The Canadian government continues to voice its commitment to funding research and
supporting policy initiatives that increase the quality of life of older Canadians. Such government
initiatives include building age-friendly communities, supporting active ageing, and funding
older adults’ health and social services (Government of Canada, 2009). These initiatives have
not, however, adequately acknowledged the needs of older immigrants (Newbold & Filice,
2006). Immigrant women ageing in Canada are increasingly ethnically and linguistically
diverse, emigrating from countries in Africa, the Middle East, Asia, and South America (Hudon
& Milan, 2016). With the increase in number and diversity of older immigrant women comes the
need to focus on healthy aging in this population. One aspect of healthy aging relates to chronic
disease management, which is concerned with both decreasing the burden of chronic disease and
improving the quality of life of older adults living with chronic illnesses (Chappell & Hollander,
2011).
Many immigrant groups in Canada and other Western nations experience a decline in
health over time with rates of stroke increasing to mirror or exceed that of the general population
(Sohail, Chu, Rezai, Donovan, Ko, & Tu, 2016). Stroke is the third leading cause of death in
Canada (Statistics Canada, 2011) and the economic burden of stroke remains high where
Canadians lose 3.6 billion dollars a year to the costs of stroke treatment and lost productivity
(Public Health Agency of Canada, 2011). As a registered nurse with a background in acute
stroke care, I was acutely aware of the debilitating and life changing effects of stroke in older
2
adults. I began to wonder about my patients’ future experiences with ongoing health
management and secondary stroke prevention when discharged to the community. I was
involved as a nurse in the stroke prevention clinic and saw patients for follow-up post stroke or
post-diagnosis of conditions that significantly increased stroke risk. I noticed the lack of health-
promoting resources that were culturally and linguistically tailored to diverse populations. The
literature mirrored this observation where discrimination, economic instability, language and
cultural barriers, and social exclusion continue to influence access to and utilization of health-
promoting resources (Scheppers, Van Dongen, Dekker, Geertzen, & Dekker, 2006; Valderrama,
2011). Such challenges can be amplified for older adults from culturally and linguistically
diverse backgrounds (Bukman et al., 2016; Tummala-Narra, Sathasivam-Rueckert, & Sundaram,
2013; Ypinazar & Margolis, 2006). Awareness of the literature and experiences as a nurse in
stroke services propelled my interest in stroke prevention in diverse older populations as a
research question.
I lived and worked in the Middle East early in my nursing career. I was aware of the lack
of health promotion initiatives targeting healthy ageing and management of chronic health
conditions. I can remember frequently participating in technically advanced acute and emergency
care interventions. I can remember less frequently engaging in discussions with patients around
prevention and management of chronic illnesses. Overall, the Arab world lacks infrastructure and
commitment at a policy level for health promotion initiatives (Al Jardali et al., 2010). What does
this mean for immigrants coming from the Arab world to Canada? I chose stroke prevention in
Arab immigrant populations ageing in Canada as a dissertation project. I chose to focus
specifically on Arab immigrant women because of my social positioning as a bicultural Arab
woman. This positioning resulted in greater awareness of the challenges women in the
3
community experienced in the context of maintaining health. I was initially interested in
women’s personal experiences and interpretations in regard to stroke secondary prevention. I
planned to target a high risk population that had already experienced a stroke or transient
ischemic attack [TIA] to allow a better understanding of the pathways of risk that lead to stroke
development and the subsequent experiences of secondary prevention. Recruitment was
challenging as the available Arab population in the local urban location was small. Finding
women who lived in the community and had experienced such an event meant an even smaller
pool of potential participants. During the first two interviews it became evident that primary
prevention was a serious area of concern for the women who explicitly stated that they had not
been aware of their stroke risk profile and had minimal stroke knowledge. Difficulty with
recruitment and insights from the first interviews propelled me to expand recruitment criteria to
include women who had not experienced a stroke but were at a high risk for occurrence.
Study Question
The research question emerged as: “What are the experiences of engaging in stroke
prevention strategies in middle-aged and older Arab immigrant women living in an urban
Canadian center in Alberta?”
Study Objectives
The dissertation research project involved recruitment of middle-aged and older Arab
immigrant women with a history of a stroke or stroke risk factors to discuss their experiences of
engaging in health-promoting practices in the context of stroke prevention. In focusing on the
specific area of stroke, attention was given to the social determinants of health across the life
course. This included attention to social and economic well-being, immigration history, and
4
education as determinants of health that shape health behaviors, access to health-promoting
resources, and exposures to health stressors. The objectives of the study were as follows:
To understand middle-aged and older Arab immigrant women’s experiences across the
life course that could facilitate or limit the ability to engage in stroke prevention
practices.
To identify gaps in resources and knowledge that hinder middle-aged and older Arab
immigrant women’s abilities to engage in stroke prevention practices.
This project is a first step towards addressing broader research objectives that include:
To identify facilitators and barriers to engaging in stroke prevention across groups of
Arab immigrants.
To identify and test strategies to enhance stroke prevention practices in Arab immigrants.
To expand the focus on stroke prevention to include other cardiovascular conditions that
share similar risk profiles and benefit from similar prevention approaches.
Definition of Terms
Middle- aged adult: A person aged 45 to 64 years of age.
Older adult: A person aged 65 years of age and above.
Arab immigrant: Arab immigrants are one of the largest non-European ethnic groups in Canada
and immigration from Arab countries continues to rise (Statistics Canada, 2007). Generally,
Arab Canadians are more likely to be educated at university level than the general population, to
have a lower income than the general Canadian population, are relatively young in comparison to
the general population, and include a high percentage (54%) of those who are foreign born
arriving in Canada from the1990s onwards (Statistics Canada, 2007). Arabs come from 22
5
countries in the Middle East and North Africa [MENA] region: Algeria, Bahrain, Comoros,
Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine,
Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates, and Yemen. The
majority of MENA countries are classified low to medium on the human development index with
the exception of countries of the Gulf region, which have high indexes.
In this study the women were immigrants from the Levant region of MENA, specifically
the Palestinian territories, Lebanon, and Syria. Criteria for inclusion were women greater than 45
years of age and who self-identified as being an Arab immigrant. All women in this study had
been in Canada for more than five years. Most women had lived in Canada for the majority of
their adult life, arriving as young brides or with young families. All women spoke Arabic
primarily with differing degrees of fluency in English as an additional language. Education
varied from illiterate to university level education. Income was low to high based on self-
reported measures. All women were living in the community with family (spouses and/or
children) except for one woman who was living alone. Ten out of the 16 women were
housewives and six others had been employed at different periods in their lives outside the home.
Secondary & primary stroke prevention: Stroke prevention involves interventions that are
designed to prevent, stop or slow the progress of stroke or stroke-related risk factors (Couttes et
al., 2015; Meschia, et al., 2016). Risk assessment tools to identify potential participants were
initially trialed and then abandoned for this study because women could not provide adequate
health information to complete risk assessments and I did not have access to health records.
Personal disclosure was used to identify women who had a stroke, TIA, or at least one health
condition that can increase stroke risk, such as diabetes, hypertension (not able to always
determine controlled versus non-controlled), hypercholesteremia, atrial fibrillation, or
6
myocardial infarction. The majority of women also had one or more modifiable stroke risk
factor, such as obesity, smoking, and sedentary lifestyle.
Study Significance
In Canada, one to two thirds of individuals affected by stroke have minor to severe
disability or impairment (Canadian Institute for Health Information, 2009). Women tend to have
greater post-stroke disability and poorer post-stroke recovery in comparison to men, which is
partly explained by older age of stroke onset, poorer pre-stroke functional status, multi-
morbidities, and poorer social support (Appelros, Stegmayr, &Terent, 2009; Persky, Turtzo, &
McCullough, 2012). The occurrence of minor strokes or TIAs indicates the presence of
underlying cerebrovascular and cardiovascular risk factors. These risk factors are precursors for
the development of more severe stroke events and other adverse cardiovascular events that
negatively impact quality of life and well-being (Couttes et al., 2015; Meschia, et al., 2016). Key
strategies for primary and secondary stroke prevention involve dietary modification, exercise,
diabetes and hypertension control, and use of pharmacological agents to reduce incidence of
vascular events (Couttes et al., 2015; Meschia, et al., 2016). Delays in seeking stroke care lead to
greater stroke severity, increased mortality, and increased post-stroke disability (Moser et al.,
2006). Therefore, prevention also involves increasing stroke symptom recognition and response.
There is ample evidence that the above prevention strategies work across ethnicities (O’Donnell
et al., 2016). Yet, success in managing stroke risk is also shaped by personal beliefs and practices
around health and by larger structural systems and processes that influence access to health
resources.
Arab populations experience a high prevalence of undiagnosed and poorly controlled
stroke risk factors such as diabetes and hypertension (Musaiger, & Al-Hazzaa, 2012; Tran,
7
Mirzaei, & Leeder, 2010), higher rates of smoking (Girgis et al., 2009), and higher rates of
obesity and sedentary lifestyles (Qahoush, Stotts, Alawneh, & Froelicher, 2010; Liu et al., 2010)
than a number of other immigrant and non-immigrant populations. There is a need for further
attention in the context of minimal stroke prevention initiatives and resources specifically
targeting the needs of Arab immigrants both in their countries of origin and destination (Berger
& Peerson, 2009; Gholizadeh, DiGiacomo, Salamonson, & Davidson, 2011; Kamran et al.,
2007). Immigrant women can be particularity vulnerable when faced with lack of social support,
economic difficulties, immigration stressors, and inadequate culturally and linguistically tailored
healthcare resources (Barn & Sidhu, 2004; Emami & Torres, 2005; Guruge, et al., 2010;
Kokanovic & Manderson, 2006; Neufeld, Harrison, Stewart, Hughes, & Spitzer, 2012; Pavlish,
Noor, & Brandt, 2010; Sethi, 2016). This research project aimed to increase understanding of
Arab immigrant women’s experiences with engaging in health-promoting practices that decrease
stroke risk and pave the way for much needed future research in this area.
Study Methodology
Interpretive Description [ID] is a qualitative methodology, developed by Thorne (2016),
which focuses on describing subjective experiences around phenomena of concern to nursing and
constructing an analysis based on shared interpretations between researchers and participants.
Interpretive Description moves from making visible individual experience to identifying patterns
of commonality and difference across experiences. Interpretive Description also has a
disciplinary goal, which is to formulate implications of research findings useful to the practice
environment (Thorne, 2016). The goal of an ID is to answer two questions: what can I learn
about this phenomenon, and how can this knowledge improve nursing practice. Sixteen women
who met the inclusion criteria of this study were recruited from a mosque and a community
8
Islamic center using convenience sampling and the snowballing technique. Initially, I used
recruitment posters (appendix A) but found this recruitment method unsuccessful. Advertising
the study in community gatherings and use of community gatekeepers to recruit potential
participants were successful methods of recruitment. The women were immigrants from the
Levant region who were living in an urban center in Alberta, and who had either experienced a
stroke event or had stroke risk factors. Recruitment and data collection occurred between June
2015 and May 2016. Data collection involved administering demographic and health
questionnaires (appendix B) and conducting semi-structured interviews (appendix C). Interviews
commenced in women’s location of choice, usually their homes. Being bilingual allowed me to
interview women in Arabic or a combination of English and Arabic. Interviews were two to four
hours in duration. Consent was obtained in Arabic (appendix D) before commencement of the
interviews. Interviews were audiotaped when consent was given and were later transcribed in
Arabic. An Arabic-speaking research assistant helped with transcription of interviews. The
research assistant signed an agreement (Appendix E) to ensure confidentiality of content in
interview transcripts.
Saturation was defined as the repetition of patterns of experiences that provided new
insights into the research topic of stroke prevention in Arab immigrant women (Morse, Barrett,
Mayan, Olson, & Spiers, 2002; Thorne & Darbyshire, 2005). Data analysis followed a thematic
inductive approach with final themes and exemplars translated into English by a certified
translator. An ID methodology relies on constant comparative analysis processes, originating
from grounded theory, to understand human phenomena (Thorne, 2016). This involved going
through four cognitive processes during the stages of data analysis (Morse, 1994): (a)
comprehending, where one generates an understanding of the context and experiences of
9
participants, (b) synthesizing, where one looks for patterns of commonalities and variations
within these contexts and experiences, (c) theorizing, where explanations for the patterns are
sought, and (d) re-contextualizing, where explanations are dwelled upon for their relevance and
meaning to practice. I completed data analysis in Arabic to minimize loss of conceptual meaning
that can occur with translation to English. Two interview transcripts were translated early on so
that my English-speaking supervisor could provide feedback about interview techniques and
development of initial categories. The first step, immersion into the data, consisted of reading
and re-reading interview transcripts. Taking a bird’s eye view of the data was followed by a
coding process that involved generating categories and searching for connections across
categories. Codes are descriptive labels designated to segments of a transcript; these labels were
linked to form categories that summarize the different aspects of women’s experiences with
stroke prevention. Thorne (2016) encourages the use of manual data analysis practices for novice
researchers to develop a personal style of inductive reasoning. I used a manual process of color
coding segments of paper transcripts and organizing these codes into different categories. The
last step involved the identification of themes. A theme is as an abstract conceptualization of
patterns of experience that informs our understanding of a particular phenomenon (DeSantis &
Ugarriza, 2000). The process of thematic data analysis involved searching for patterns of
similarity and difference in experiences while simultaneously looking at the contextual factors
that influenced the development of these patterns (Sandelowski, 2003). Audit trails, used to
increase transparency in the research process (Meadows & Morse, 2001), were kept to record
thought processes and approaches used from early data collection to later interpretation of
research findings (Appendix F). The dissertation is a compilation of the research process and the
10
final interpretive outcomes and includes three core papers that address the ethical considerations
of the research study (chapter two) and the resulting findings (chapter four and five).
Conceptual Framework: An Emergent Process
The dissertation research project aimed to understand Arab immigrant women’s
experiences of engaging in health –promoting practices related to stroke prevention as they age
in Canada. Different theoretical perspectives informed the research process; from life course
theory and intersectionality to transnationalism. Thorne (2016) refers to the term ‘multiple
truths’ to describe knowledge outcomes of qualitative research processes. I use the term
‘contextual truths’ to frame the way I conceptualize the production of knowledge in the research
project. By ‘context’ I mean the spatially and temporally contingent realities that shape
experiences and interpretations of those experiences. I discuss context throughout the dissertation
in relation to three contexts that I see influencing the research process: intra-personal, inter-
personal, and extra-personal. The intra-personal context relates to the researcher’s reflexive
activities and the inter-personal refers to the relational dynamics between researchers and
participants. Both the intra and inter-personal contexts are contingent on the social positioning of
the researcher and researched community. These dimensions are discussed in chapter two and in
appendix F, where the relevance of context is highlighted in relation to ethical and
methodological research considerations. The extra-personal context centers on the external
processes, structures, and practices that influence the way a particular phenomenon is
experienced and interpreted in research. Data collection and analysis always involves a process
of construction; I believe that ignoring context can lead to constructing in the dark. In chapters
three and four, the study findings are situated in the context of geographical, social, political, and
11
economic realities. Different conceptual frames allowed me to situate the findings of the study
in context and to focus on different particulars.
The move towards integrating aspects of life course, transnational, and intersectional
theoretical approaches during the research process was a result of the ways I came to understand
the intersections of immigration, ageing, and health. I saw immigrant health as influenced by pre
and post-migration social, political, and historical factors across the life course. Women in this
study came from the Levant region and the majority arrived in Canada in the late sixties to early
eighties. Many experienced similar macro political events, immigration policies and social norms
despite variations in personal particulars. Life course theory captures the temporal and spatial
dimensions of influences on immigrant health through the concepts of cohorts, trajectories, and
transitions. Life course approaches also focus on the interaction between personal agency and
broader structures and systems. I used life course theory to frame my interview guide and as an
informing perspective during data analysis. I drew specifically from Elder’s work on life course
theory (Elder & Giele, 2009) and the work of other researchers concerned with life course
influences on immigrant health (Gong, Xu, Fujishiro, & Takeuchi, 2011; Montes de Oca, García,
Sáenz, & Guillén, 2011; Nicolau & Marcenes, 2012; Spallek, Zeeb, & Razum, 2011).
A critique of life course theory is that it lacks cultural relevance and reinforces a Western
conceptualization of the life course (Elder & Giele, 2009; Holstein & Gubrium, 2007).
Intersectional perspectives consider the influences of multiple social locations such as ethnicity,
gender, and class on the progression of the individual life course. Transnational perspectives
expand the notions of social locations across local, regional, and global spaces to address the
ways immigrants construct their lives within these spaces. Chapter three addresses the social
dimensions of health, identified in women’s stories, across the life course within different
12
migration contexts. Chapter four looks at the barriers and facilitators to stroke prevention from
an intersectional perspective incorporating local, national, and global influences on health. In the
final chapter of the dissertation, I draw from my experience of using these theoretical approaches
in research with Arab immigrant women to present guiding concepts that can inform future
nursing practice and scholarship that exists at the intersection of immigration, health, and ageing.
13
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21
Chapter Two
Title: A Bicultural Researcher's Reflections on Ethical Research Practices with Muslim
Immigrant Women: Merging Boundaries and Challenging Binaries.
Authors: Jordana Salma, Linda Ogilvie, Norah Keating, Kathleen F. Hunter
Journal: Advances in Nursing Science, Vol 40, Issue 2.
Status: Accepted for Publication on March, 3, 2017.
Abstract: Bicultural researchers are well positioned to identify tensions, disrupt binaries of
positions, and reconcile differences across cultural contexts to ensure ethical research practices.
This article focuses on a bicultural researcher’s experiences of ethically important moments in
research activities with Muslim immigrant women. Three ethical principles of respect, justice,
and concern for welfare are highlighted, revealing the implications of binary constructions of
identity, the value of situated knowledge in creating ethical research practices, and the need to
recognize agency as a counterforce to oppressive narratives about Muslim women.
22
Chapter Two
A Bicultural Researcher’s Reflections on Ethical Research Practices with Muslim
Immigrant Women: Merging Boundaries and Challenging Binaries.
Muslims living in the West experience racism and xenophobia as global politics and
power struggles play out within local communities. Health literature on Muslims often
emphasizes difference, reproduces colonial representations of the other, and fails to capture
diversity within Muslim populations (Laird, Marrais, & Barnes, 2007). Muslim women have
been particularly enmeshed in discourses of identity, power, and religion in the West and
globally (Charad, 2011). These discourses often center on the idea of irreconcilable binaries of
identities, positions, and values between Muslim and non-Muslim and between East and West.
These discourses shape the ways researchers frame research questions, design research studies,
and engage in ethical decision-making with Muslim communities (Laird, Marrais, & Barnes,
2007). As a bicultural Muslim researcher, such discourses influence my sense of self, color my
interpretation of the world, and shape interactions with communities within which I live in ways
that serve to both reinforce at times and disrupt in others existing binaries. I am a Muslim
woman with Arab and European heritage pursuing a graduate degree at a Western university. I
embody the tensions created by binaries of identities, values, and power positions and bring an
awareness of them into my research activities.
In this paper, I focus on ethical decision-making during research activities with a group
of immigrant women in a Muslim Arab community in Canada. The objective of the study was to
better understand the facilitators and barriers to engaging in health promoting practices. Sixteen
women participated in the study over a period of one year. The women formed a cohort that had
23
immigrated to Canada in the 70s and 80s from the Levant region. I recruited women from both a
Mosque and a Muslim community center, a pragmatic choice based on perceived community
support for the research project. Researchers in cross-cultural settings can experience tensions
due to competing expectations, loyalties, and interpretations within a research context (Bolak,
1996; Ganga & Scott, 2006; Manohar, 2013). When left unaddressed, these tensions jeopardize
research quality and ethical commitments of a researcher to the participating community. I use
my position as a bicultural Muslim woman to highlight the ways dominant discourses of binaries
and difference serve to exacerbate ethical tensions and I look for an alternative lens from which
to approach research within Muslim communities. My experience of reconciling ethical tensions
involved processes of merging boundaries and challenging binaries.
Merging boundaries relates to a paradigmatic shift where Islam was placed at the center
of Feminism when engaged in ethical decision-making. Challenging binaries relates to
problematizing prevalent notions of identity, values, and power positions created by the social,
historical, and political milieu within which I and the participating community exist. I provide
concrete examples of reconciliation by highlighting ethically important moments in the research
process, defined as instances where a decision or action has ethical ramifications and is a source
of discomfort for the researcher (Guillemin & Gillam, 2004). The ethically important moments
were often nuanced, open to interpretation, and at risk of fading in the backdrop of more
ritualistic and normative ethical research standards. I reflect on the three ethical principles of
respect, concern for welfare, and justice in ways that highlight implications of binary
constructions of researcher and researched identity, the value of situated knowledge in creating
ethical research practices, and the need to recognize agency as a counter-force to oppressive
narratives about Muslim women.
24
Merging Boundaries: Islam at the Center of Feminism
Making Sense of the Many Shades of Feminism
As a woman engaging in research activities with other women, I utilized Feminist
perspectives to help shape the research agenda, identify research methods, and guide
interpretations of women’s experiences. As a Muslim engaging in research activities with other
Muslims, I was aware of historical and political narratives that describe Feminist and Islamic
perspectives as incompatible. Central to Feminist orientation(s) is a commitment to social justice
as a moral imperative (Hartsock, 1996) and an epistemology that defines knowledge production
in terms of subjectivities and multiplicities stemming from the lived experiences of women
(Harding, 1987; Haraway, 1988). In the early twentieth century Muslim women activists drew
attention to gender equity and women’s rights issues, in response to the dire condition of
women’s lives during and after colonialism (Seedat, 2013). This activism included a range of
movements, from secular to religious, where the label of Feminism was adopted by some and
rejected by others. Muslim women struggled with the inherited baggage of Feminism as a by-
product of European Enlightenment, a concern specific to white middle-class women, and a tool
to reinforce the colonial notion of white men and women saving “brown women from brown
men” (Mohanram, 1999). The rise of other Feminism(s)- Post-Colonial Feminism, Black
Feminism, and Subaltern Feminism- expanded the Feminist lens to incorporate understandings of
the interweaving systems of domination created by racial, gender, and class oppression (Anthias,
2002; Mohanram, 1999; Mohanty, 1991; Spivak, 1988). These Feminism(s) address the
materialization of power within the production of knowledge and public discourses, the creation
of social norms, practices, and institutions, and the lived experiences of women.
25
The conflation of a Western Feminism with other Feminism(s), however, still remains
problematic in Muslim and Arab contexts with the rise of oppositional extremist narratives
characterizing the West and East as a “clash of civilizations” (Cooke, 2001). I was engaged in a
continuous process of locating differences, merging perspectives, and imagining possibilities
when faced with potentially irreconcilable standpoints. I could see the merits of other
Feminism(s), but also pitfalls when a Eurocentric Feminist lens is used to focus in on women’s
issues within Muslim communities. Although great strides have been made in the use of
relational Feminist approaches to conduct health research with minoritized populations
(Anderson, 2004; Kirkham, Baumbusch, Schultz, & Anderson, 2007; Racine & Petrucka, 2011),
I would argue that the use of such approaches have been limited in health research within
Muslim communities, resulting in essentializing of identities, reliance on overly culturalist
narratives, and lack of attention to historical, political, and structural influences on Muslim
women’s health. I would also argue that a barrier to translating relational feminist perspectives
into ethical research approaches with Muslim women continues to be the lack of conceptual tools
that from inception incorporate the perspective of the Muslim Other.
Re-imagining Islamic and Feminist Convergence
For researchers, a centering of Islam in Feminism can serve to guide research activities
with Muslim women by providing a relational approach that privileges the point of view of the
Other. Muslim women’s work on gender equity and women’s rights have begun to incorporate
definitions that converge Islamic and Feminist ideals, creating new possibilities such as
Tawhidic Paradigm (Wadud, 2008), Muslim Holistic Feminism (Badran, 2011),
and Critical
Faith Centered Feminism (Zine, 2004). These Muslim scholars/activists share the belief that
Islam inherently includes a historical gender consciousness that precedes Western Feminism.
26
This notion stands in opposition to Western metanarratives of Muslim women, stories tragically
told, all calling for the liberation of Muslim women from the grasps of a patriarchal Islamic
tradition. Feminism, as defined by Cooke (2001) in her introductory chapter is a “changing state
of consciousness” that reflects women’s understanding of themselves and their position in the
world, making it neither culturally nor regionally bound. She defines Islam as a “spiritual and
cultural nation” that creates a common space for resistance to the colonial intentions of the West.
The term West does not signify a geographically bound region but rather refers to capitalist and
neocolonial hegemonic structures of power that shape discourses, division of material and
knowledge resources, representations of identity, and, hence, the lived reality of everyday
experiences (Badran, 2011). Cooke (2011, p.113)
argues that Islamic and Feminist perspectives
can be utilized together in acts of “multiple critique” to expose corruption, create new
possibilities, and build spaces for empowerment and agency. This is the approach I felt morally
and ethically inclined to use when engaging in research activities with Muslim women.
Not all Feminists see Islam and Feminism as reconcilable nor do all Muslim women
activists call themselves Feminists (Seedat, 2013). Despite a multiplicity of positions, Muslim
women who take on gender equity and women’s rights struggles cannot escape what Cooke sees
as a double commitment to one’s faith on one hand and to women’s issues on another. This
commitment entails resistance to both patriarchal nationalist agendas and capitalist hegemonic
systems of power (Zine, 2004). In a local research context, this commitment interprets into
awareness and resistance of the complex and inter-related structures of oppressions that
materialize within women’s lives. It also means acknowledging that personal religious practices,
religious identities, and broader political, historical, and social processes are inter-twined and
counter-influencing. The identity label of Muslim, when situated within broader social and
27
historical structures, impacts the daily lives of Muslim women irrespective of personal
religiosity. Like gender and race, religion has multi-level and inter-related implications in
shaping women’s lives (Klassen, 2003; Reimer-Kirkham & Sharma, 2011). Subsequently as
Muslims, who we say we are, how people see us, and how we interact within broader society
influences our access to and participation in research activities. For researchers engaged in
research activities with Muslim communities, becoming familiar with the perspectives of Muslim
women who lead Feminist struggles, the discourses that support or hinder their efforts in the
Muslim world, and the interweaving narratives that bridge cultural and religious divides can
illuminate and facilitate research processes in local contexts.
Moving towards an Islamic Feminist Ethics
A Feminist ethics is concerned with locating power and resisting oppression, in all its
forms, for all women. Feminists have long argued for a relational ethics that gives privilege to
the world-views of those they research (Anderson, 2002; Fisher, 1997). This partially means
incorporating into the design and implementation of a research study the ethical and moral
perspectives that guide research participants. Muslim Feminists describe a centering of Islam in
Feminism where Islamic perspectives constitute the departure point for social, historical, and
experiential understanding (Seedat, 2013). Feminism remains a tool for critique, dialogue, and
political solidarity within Muslim communities and globally. Ethical research involves
understanding Islamic principles that ethically and morally guide Muslims, deconstructing the
ways these principles come into being, are interpreted, and implemented using gendered and
racialized lens, and creating spaces of dialogue to share Muslim women’s experiences. Ethical
research privileges difference based on alternative historical, social, and political realities and
recognizes the power structures across Western and Islamic contexts that serve to disempower
28
and silence women. Research activities morphed into a process of heightening awareness. I
began to recognize the positionality of the women within their families, their community, and
broader society. This positionality was structured around the negotiation of power horizontally
and vertically in their lives, becoming evident in the particular experiences of recruitment,
consent, and data collection.
Women questioned the objectives of the research project, recognizing the minoritized
status of Muslim women in Canadian society, the misconceptions about them, and the need to
create spaces for community engagement and dialogue. Women negotiated participation,
involvement of family in the research process, and the level to which their private lives were to
be made public. Implicit in giving consent was the condition that I, the researcher, avoid the
essentialized and unitary objectification of the Muslim subject. Women constructed stories of
themselves that revealed the particular within the collective, balancing individual narratives with
acknowledgement of the disciplinary forces that governed their lives. Mohanram (1999, p.82)
suggests women’s bodies are coded racially, culturally, socially, sexually, and nationally,
carrying within them the privileges and burdens of such embodiment. I came to realize that the
women and I were engaged in the illusive quest for a disembodied self. In the following section,
I describe the interplay of identity, values, and power positions that unfolded in the research
context.
Challenging Binaries: Identities, Values, and Power Positions
I defined myself from the onset of the study as a bicultural researcher. I am a Muslim
woman in my early thirties. I was born in Canada to a mother of European heritage, lived in the
Middle East and West Africa for 25 years, and was living in Canada with my family at the time
of the study. Being a Muslim with Middle Eastern heritage on my father’s side and having lived
29
in the Middle East created grounds for connection with participants. Having European heritage
from my mother and an Arabic accent that hinted of a bilingual tongue were grounds for
questioning origins and belonging. Being born in Canada also meant I could not personally
identify with the immigrant experience fully. This was often acknowledged by community
members who in describing a part of their immigration experience would end with: “It is
different for you, you were born here.” This comment was in juxtaposition with another frequent
question by some Canadians: “Where are you really from?”
The binary distinction between Muslim and non-Muslim and between Western and non-
Western are based on political and historical representations which are contested, forced, and
exploited within various ideological agendas (Said, 1994). From the Colonial representations of
the Muslim Arab Other to nationalist and religious representations of a unifying Muslim or Arab
identity, history is rampant with examples of a watered down and bland Arab and Muslim
identity construct (Said, 1994). Not so often recognized in health research is that using the term
Muslim and Arab identities as a plurality reflects more accurately how people within these
communities define themselves and relate to one another. The labels of Arab, Muslim, and
female are often attributed to individuals in health research with little attention to influences of
class, education, region of origin, life history, and personal attributes (Charad, 2011). The women
in this study embodied complex and multilayered identities beyond being Arab and Muslim that
shaped their life experiences, their values, their power positions, and, consequently, their
interactions with the researcher over the course of this study.
I acknowledge the tension between emphasizing differences to de-objectify the Muslim
Arab woman and isolating Muslim Arab women as a group cohesive enough to warrant focus in
a research study. This tension is described by Cooke where feeling the tantalizing gaze of
30
outsiders Muslim communities emphasize their collective attributes in resistance to their
disempowerment, but when unthreatened emphasize their multiple and multifaceted selves. She
states: “Where we are and with whom changes how we speak; it may even change what we say.”
(Cooke, 2001, p.138). To belong to the same culture is to belong roughly to the same conceptual
and linguistic universe, to know how concepts are referenced in different languages, and how
language can be interpreted to reference the world (Hall, 1997). Culture, in this sense, is a
process or a set of practices. Shifting from a definition of culture as a fixed group attribute to
culture as a process that is continuously reinvented and redefined means that a person’s cultural
expressions and interpretations shift across the life span within different social spaces.
Muslim Arab women share a common linguistic heritage despite differences in regional
dialects, share common experiences of struggle against patriarchal and colonial systems of
domination despite variations in degree of oppression, and share Islam as a historical and socio-
political influence in their lives despite varying degrees of religiosity. I am a Shia Muslim from
the Southern region of Lebanon. Lebanese Southerners would want to know that my mother is
Ajnabiyi -a Westerner- that my father comes from a specific area in Tyre, the Ally of Egyptians,
that my family includes notable television personalities and upper class business men, and that I
married into a Sunni family from the North of Lebanon. Only this level of detail would satisfy
participants as sufficient to know where my loyalties are likely to lie, the level of trust I can be
given, and which parts of my experiences mirror that of the collective. Although I identified with
women in the community along ethnic, religious, and gender lines, the sense of belonging,
reciprocity, and responsibility stemmed primarily from a common experience of being perceived
in a Western context as the foreign Other.
31
Embracing Complexity in the Research Context
My relationship with the community, similar to that of other researchers (Monohar, 2013;
Weiner-Levy & Abu Rabai Queder, 2012; Zubair, 2015), could not be understood within
discourses of binaries. I was trying to balance subjectivity and objectivity, belonging and not
belonging, and investing the inner self with distancing the self. I felt a constant worry about the
potential for partial belonging jeopardizing authenticity of research findings and partial
outsiderness jeopardizing ethical sensitivity. As a bicultural researcher working within a Western
university, Foucault’s panopticon symbolizes well processes of self-monitoring where
researchers internalize the disciplinary function of the research institution. A panoptican is a
structure, often a prison that allows visibility of all who inhabit it at all times by a single guard.
Inhabitants are unaware of when they are watched and are forced to govern their actions as if
they always are. Foucault used a panoptican to symbolize the way power functions in society. As
opposed to seeing power as a top down exertion of control over others, Foucault saw power
functioning as a disciplinary force internalized in the self and resulting in self-monitoring by the
individual at a sub-conscious level to ensure alignment of the self with the expectations of power
elites and institutional structures (Mills, 2003). Bicultural researchers often remain unaware of
their subjugation within institutional hegemonic discourses, yet I believe possibilities for
awareness can arise from the shocking volts of moral tension in those ethically important
moments of doing research. I have internalized other ways of knowing that color the way I see
the world and regulate my reactions to it. These ways of knowing stem from growing up as a
child in the care of an observant Muslim grandmother, participating in the worlds of two
colonized continents, and speaking a language rich in alternative histories. The political becomes
32
personal for a bicultural researcher, as the multiplicities of disciplinary forces burden the body
and shape subjectivities.
I came to realize that within ethically important moments in the research process tensions
would manifest when ethical decisions potentially opposed the norms of the research institution.
What if I had embraced from the onset the messiness and fluidity of my social location, made
explicit my personal and political commitments unapologetically, and created space for shared
construction of ethical perspectives? This would have meant recognizing that what is ethical was
not my decision to make alone. This would also have required engaging in a reflexive process
that sees methodology, epistemology, and ethical action as intertwined and interdependent
(Haraway, 1988; Mohanram, 1999; Mohanty, 1991). This does not mean I advocate abandoning
the ethics of academic institutions that ensure a basic foundation of ethical research activities.
Like other Feminist and Post-Colonial researchers (Anderson, 2004; Reimer-Kirkham & Sharma,
2011; Racine & Petrucka, 2011), I argue for expanding and building on these principles in ways
that address the concerns of communities with which we engage in research. In the following
sections I focus on the reconciliation process that was needed to uphold the principles of respect,
concern for welfare, and justice. I chose to focus on these three principles as being common
terms used in research ethics policies in Western and Muslim contexts (Canadian Institutes for
Health Research et al., 2014; Fadel, 2010).
Reconciliation within Ethically Important Moments
Navigating Identities to Ensure Respectful Interactions
Navigating identities was part of ensuring respectful interactions with the Muslim
community and the women who participated in the research study. When women agreed to
participate in the study by giving verbal consent, they were agreeing to do me a favor and help
33
their community. Recruitment methods included using flyers and using community gatekeepers
to advertise the study. In-person introductions through formal information sessions, community
volunteering, and involvement in social events was the only successful method of recruitment.
Many women admitted that I was allowed into their homes because I was one of them. I was
perceived to be a good Muslim woman who was working hard to study and support her family
and, thus, deserved support. Yet, in building trust, I had accentuated one aspect of my identity
and downplayed another. I was a doctoral student who would take the collected data and place it
in the public sphere. I was motivated by multiple world-views that might or might not have
converged with the views of community members. Moving from the recruitment phase to the
written consent process, the emphasis became on my position as a researcher. This experience
has been reiterated by another Muslim researcher (Zubair & Victor, 2015), where the consent
process shifts the interaction from friendly and relaxed to formal with institutional and
governmental overtones. In response to this shift, women either showed hesitance to participate
or trivialized the process by agreeing to sign the consent form without asking questions. The
consent process had to move away from being an efficient and standardized formality. The
process became one of understanding root causes of discomfort, illuminating the hidden
processes of the research institution, and looking for common ground on which to move forward.
Explaining the role of an ethics board, the need for confidentiality and anonymity, participants’
right to withdraw or refuse questions, and purpose of data collection were all crucial elements in
the consent process. I learnt to strike a balance between too little and too much information,
define and translate terms in a simple and clear language, and overcome the barrier of illiteracy.
Some women spoke Arabic but were illiterate. I audio-recorded participants’ verbal
consent in such cases and, often, literate family members reviewed the consent form as well. In
34
the literature on Muslim populations verbal consent has been advocated as a legitimate cultural
practice and, hence, necessary to ensure cultural sensitivity (Aroian, Katz, & Kulwicki, 2006;
Mohammadi, Jones, & Evans, 2008). Potential participants might refuse written consent due to
the perceived legal nature of signing a document, fear of negative implications of giving consent,
or inability to read the consent form. I was concerned that verbal consent might be interpreted,
wrongly, as less of a formal commitment or more likely to safeguard their concerns around data
usage. I emphasized the role of the ethics board in monitoring my research activities as a
doctoral researcher, including whether or not consent was free and informed. This approach
seemed to put participants at ease, as the act of signing the consent form became one of holding
the researcher accountable, not the participant. All women agreed to participate in the study after
the initiation of the consent process. One woman asked me to write down the term “ethics” so
she could research the comparative term in Arabic. Some women questioned access of
government to interview data. Two women refused to be audio-recorded for interviews but
allowed note taking.
Ethically important moments during the processes of recruitment and consent also
emerged from the need to balance notions of personal autonomy and notions of community
responsibility (Canadian Institutes for Health Research et al., 2014). Fostering community trust
and building personal relationships with potential participants are important for recruitment
success in Muslim communities (Aroian, Katz, & Kulwicki, 2006; Mohammadi, Jones, & Evans,
2008; Zubair & Victor, 2015; Weiner-Levy & Abu-Rubai-Queder, 2012). The most successful
recruitment strategy involved face to face interactions with potential participants. I attended
social and religious gatherings, publically presented my research project, and volunteered in a
recreational senior’s group. I was conscious about avoiding the implicit message that the good
35
Muslim thing to do would be to participate in the study, especially since recruitment was
occurring in religious settings. Islamic teachings emphasize a collective consciousness regarding
social justice issues where personal autonomy and interests of the community are always in need
of balance (Atighetchi, 2009; Chamsi‑Pasha & Albar, 2013). It would be difficult to separate the
recruitment process in Muslim communities from beliefs around obligations towards furthering
collective good. The potential for coercion in observant Muslim groups does not relate only to
the material and social but to the spiritual as well. A potential participant’s sense of obligation
could stem from perceived obligations to the researcher, to community members, and to God.
Phrases such as “Muslims need to help one another” and “we need to support our Muslim
community” were common utterances by community members. Problematizing these comments
means we simultaneously recognize the potential for agency and the potential for coercion.
Emphasizing a community’s need to participate in research and an individual’s right to refuse
can become conflicting messages. I often received positive feedback from participants, where the
interview process was an opportunity to socialize or vent troubles to a sympathetic listener. The
lower number of recruits in comparison to the number of potential participants might point to
coercion not playing out in this context. Also, the few community women who helped with
recruitment through advertising the study by word of mouth and gaining consent from women to
be approached for participation were not in positions of power where coercion could manifest.
Community leaders gave their approval of the study to increase legitimacy within the community
but were not involved in recruitment activities.
Valuing Situated Knowledge in the Pursuit of Justice
Justice refers to fairness and equitable treatment of others (Canadian Institutes of Health
Research et al., 2014). Justice in this context largely involves just representation through a
36
rejection of a totalizing transcending objectification of Muslim women. Muslim Feminists
continue to address the issue of justice in the context of the lived experiences of Muslim women
and in the structural, political, and cultural discourses around Muslim societies (Cooke, 2001).
My initial interest in researching Muslim Arab communities resulted from a sense of inequity in
knowledge production where the rise of chronic disease is coupled with minimal research
capacity to address the issue (Jabbour, 2014). Concepts such as “intersectionality”
(Yuval-Davis,
2006) address the intermeshed and multilayered influences of multiple social positions on
women’s location within structures of power across temporally and spatially contingent contexts.
Important in health research around Muslim Arab women is the need to avoid conflating identity
constructs with locations of power that shape community and individual narratives. There is a
strong focus on women in research related to Arab and Muslim populations, with a bias towards
seeing them as vulnerable, voiceless, and in need of rescue from their Arab male counterparts
(Beitin, Allen, & Bekheet, 2013). Conflating vulnerability with gender oppression can
overshadow the complex ways oppression materializes in the lives of women (Mohanty, 1991).
Also, equating identity categories with positions of vulnerability erases the multiplicity and
fluidity of positions Muslim women occupy in any given time (Anthias, 2002; Yuval-Davis,
2006). Researchers affiliated with higher institutions of learning are part of the higher echelons
of power, meshed into intersecting structures of power, and can be complicit in speaking for
those they research. Without the recognition of women’s “epistemic privilege”, their unique
position in understanding the conditions of their lives, projects of activism will lack relevant
frames of reference to create strategies for resistance and to procure political momentum
(Wadud, 2008). Justice can only materialize in research with Muslim women if political activism
occurs simultaneously while attending to both the micropolitics of women’s everyday lives and
37
the larger societal processes that recolonize cultures and identities (Haraway, 1988; Wadud,
2008).
Ethically important moments arose from family members’ involvement in the data
collection process. Informal participation of family members in the data collection process has
been noted in non-Western cultures (Aroian, Katz, & Kulwicki , 2006; Killawi et al., 2014). The
close role family members played in the women’s health, the lack of research addressing the
perspectives of Arab Muslims, and family members’ expressed desire to add their voices to the
study meant tensions arose in creating spaces for women to speak while acknowledging the
valuable insights of family members. Participants were comfortable being interviewed at home
but at times their homes were small with a single common family area. This meant family
members often sat with us drinking coffee and offering their insights into my questions during
the interviews. Obtaining consent was frequently a family affair where spouses and children
listened to the explanation and clarified concerns. Family presence during the consent process
was a display of support and concern for women’s best interests. Some women chose not to have
their family involved, stating that they were comfortable doing this independently. Family
members were often curious and wished to provide their perspectives on health issues facing the
Muslim Arab community. When family was present during an interview, I explained the study to
family and welcomed their presence. The questions were still directed to the participant, but
when family interjected, input was welcomed and further insights encouraged. Often family
members discussed their personal health problems and sought advice. I questioned what to do
with the information provided by family members. Often family would give verbal consent for
their information to be used in the study but since the original study did not take into
consideration family input and this possibility had not been presented to the ethics board, I made
38
the decision to exclude any of this information. When participants requested their family
members explain or clarify information for the researcher the information was included as part of
the data.
The insights and presence of family did influence the type of data collected and increased
complexity of understanding of community and family health issues. I felt, however, that the
concept of justice towards the community was compromised by excluding voices that seldom
had a space to express concerns. It would be useful for researchers designing studies with similar
populations to incorporate into the study a space for the voices of family members. It can be
argued that family involvement hindered women’s ability to tell their stories in an unconstrained
manner and, hence, jeopardized data collection. Women who were interviewed alone were more
prone to emphasize life stressors within family life and difficulties coping. These women
approached the interview process as an opportunity to vent troubles they could not share
elsewhere. Women who were interviewed with family members emphasized resilience when
family difficulties were discussed and steered away from potentially sensitive topics. This
difference was especially evident when children joined the interview process of two women mid-
way, resulting in a dramatic shift in the tone and focus of their answers to interview questions.
Women were revealing different truths about their lives to different audiences, meaning access to
different types of data. The tension between family involvement and creating unconstrained
spaces for sharing was ongoing in the data collection phase of this study.
Recognizing Agency in Concerns for Welfare
Concern for welfare involves minimizing harm that can come from engaging in research
and maximizing potential benefits (Canadian Institutes of Health Research et al., 2014). A
danger of addressing welfare in research with Muslim women stems from identity constructs that
39
are culturally and historically bound, where women are viewed as unable to comprehend
complexities of the research process, identify their best interests, or recognize the forces that
shape their lives. Researchers then feel the need to think for, act for, and decide for research
participants to safeguard their welfare. In the aim of protecting those they research, researchers
unintentionally re-inscribe colonial discourses of the Other (Mohanram, 1999). Once I had
gained access to the community, established a trusting relationship, and cemented my
community membership, I began to ask myself what the community needed from me. Arab and
Muslim researchers in other contexts have reflected on this need to ensure reciprocity beyond
what would be expected of a Western researcher (Hawamdeh & Raigangar, 2014; Morsy 1988). I
was entering spaces designated for religious and spiritual reflection, asking women to donate
valuable time to my cause, and interrupting the flow of their lives to do research. Day to day
interactions with the community revealed the need to engage, to feel with, and to act in tangible
and continuous ways in support of seniors’ health and social initiatives. This Muslim community
had minimal access to material and knowledge health resources that were linguistically and
culturally appropriate. The item on the consent form stating that no personal benefits were
expected from study participation seemed irrelevant. It can be argued that a bicultural researcher
who works to increase perceptions of belonging also increases community expectations of
reciprocity and, hence, will struggle with the moral obligations to meet these expectations. A
sense of ongoing obligation towards the community interpreted into decision-making that
favored enhancing agency and supporting women in managing their health. This sense of
obligation also resulted in tensions when attending to the welfare of the community meant I
engage in non-research activities, muddying the boundaries between researcher, healthcare
professional, and friend.
40
An alignment with Islamic Feminist ideals helps balance my sense of obligation as a
Muslim, my role as a researcher in advocacy and empowerment, and the need to ensure quality
research outcomes. One strategy implemented was volunteering in a non-essential position with
a recreational senior’s group. I was available to chat with seniors, provide information on
community resources, and listen to community concerns. One contribution included locating an
appropriate exercise video for seniors, which the group continues to use. I interviewed the
majority of participants in their home, meaning I was more intimately aware of their living
conditions and health practices. This increased the role conflict between researcher and nurse
(Locher, Bronstein, Robinson, Williams, & Ritchie, 2006). Participants often requested
information on snow removal services for seniors, English language classes, and health literacy
resources. For participants with multiple vulnerabilities related to illiteracy, language and
cultural barriers, financial restraints, and transportation barriers, it was rarely possible to find
relevant community and health resources. I addressed knowledge gaps such as necessary lifestyle
modifications and side effects of different medications. Education was provided at the end of
interviews, as data collection partly involved identifying health literacy. I found myself musing
over the need to strengthen my nursing competencies to better answer questions or provide
teaching to participants.
Some participants saw us as developing a new friendship. When these participants were
more vulnerable, their reference to friendship was stronger. Gestures of friendship included
offering food, requesting future home visits, and asking to meet my family. I accepted the food,
being the culturally respectful thing to do, but did not engage in social visits to participants’
homes after the interviews. As I was involved in the community as a volunteer and attended
social and religious events, social interactions with many participants continued after the
41
interviews. I was seen as a confidante, counselor, and professional where recruitment and data
collection also included providing comfort and encouragement. However, the concern for
welfare was reciprocated by the community. I often received advice about marriage, children,
and religion as older community members shared words of wisdom.
Simultaneous recruitment, data collection, and socialization within the community
increased the risk of compromising confidentiality and anonymity. Confidentiality refers to the
need to keep collected data safe from unauthorized use, disclosure, loss, or alteration (Canadian
Institute of Health Research et al., 2014). It is important in small communities, where social
networks are extensive, to recognize the ease of identifiable information being traced back to
participants. Due to a lack of experience with research, women did not initially grasp the concept
of confidentiality. I was often asked if I had interviewed a specific person, how the interview
went, and if they had told me about a specific event. Other times community members shared the
information considered relevant to my research about participants, which participants had
withheld from me. This information was never explicitly introduced into the study but could not
help but influence my perceptions during data analysis. Confidentiality is emphasized in Islamic
teachings as a practice that prevents malice in society (Alahmad, Al-Jumah, & Dierickx, 2012). I,
also, explained the conditions of confidentiality set by research ethics boards and research
policies. Using both Islamic and Institutional references, I justified not revealing who I had
interviewed or details of the conversations. Participants sometimes told others that they had been
interviewed to encourage participation. This occurred during the snowball method of
recruitment, where one participant located another potential participant. Interestingly, this was
almost never successful in increasing recruitment. One participant informed me, on arriving to
her house, that she had just finished conversing with her friend whom I had interviewed an hour
42
ago and knew the questions I would be asking. Confidentiality could not be fully ensured during
recruitment and data collection. This means attention to anonymity must be emphasized during
data dissemination, especially in regards to unique personal stories and life events that might be
common knowledge in the community.
Conclusion: Reflecting on Tensions and Imagining Possibilities
This paper summarizes my reflections as a bicultural Muslim researcher engaging in
ethically important moments with Muslim immigrant women. For researchers involved with
Muslim communities, this paper highlights some of the ways ethical tensions can materialize
when dominant narratives focusing on binaries of difference are unchallenged within particular
research interactions. I see bringing Islam in from the margins using Feminist tools of
engagement as a possible strategy to reconcile ethical tensions. Cooke (2001, p.184) describes
Islamic Feminists as coming into “representation from the margins” in ways that disrupt
dominant discourses and challenge metanarratives that define and limit Muslim women. This
coming in from the margins involves building knowledge around ethical and moral perspectives
of Muslims, as they continue to morph and re-morph within intersecting influences of culture,
gender, class, and race. It also involves seeing Muslim women as a conduit for agency, while
simultaneously recognizing the patriarchal and colonial powers that constrain us all, albeit in
different ways and to different degrees. Lastly, it is necessary to disrupt the binaries of West
versus non-Western, us versus them, and subject versus object to create participatory spaces of
engagement and solidarity amongst women, while recognizing the horizontal and hegemonic
power struggles that limit this process.
Ethical research with Muslim communities entails researchers develop a strong personal
foundation of understanding around local and global influences in the lives of Muslim women,
43
reflect on personal identity, values, and power positions in the research dynamic, and ensure that
Muslim women’s needs, beliefs, and goals are incorporated into the research process. This paper
focuses on my experiences and interpretations and, hence, fails to capture the full range and
complexity of the community’s experience. At best this paper adds my voice to a plethora of
Muslim women who speak from varying standpoints. Some voices are heard more clearly than
others, with some remaining whispers drowned out by the roaring hum of academic elitism,
global capitalism, and nationalist extremism. Finding ways to create participatory spaces that
engage Arab and Muslim communities in discussions about ethical research practices remains a
future objective.
44
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Chapter Three
Title: Social Dimensions of Health across the Life Course: Barriers and Facilitators to Engaging
in Health-Promoting Practices in Middle-Aged and Older Arab Immigrant Women.
Authors: Jordana Salma, Norah Keating, Linda Ogilvie, Kathleen, F. Hunter
Journal: Nursing Inquiry
Status: In process of submission
Abstract: The increase in ethnically and linguistically diverse older adults in Canada calls for
attention to healthy ageing in this population. This study presents the experiences of a sample of
middle-aged and older Arab immigrant women engaging in health-promoting practices in the
context of stroke prevention. Women describe their experiences of social connections, social
roles, and social support constructed and maintained within transnational spaces across the life
course. Five themes emerge that point to the relevance of social dimensions of health in creating
barriers and facilitators to healthy ageing in this population: (a) the necessity of staying strong,
(b) caring for self while caring for others, (c) double jeopardy of chronic illnesses and loneliness,
(d) inadequate support within large social networks, and (e) triple ingredients of empowerment.
These findings point to the need to incorporate an understanding of transnational connections
and post-migration social support into initiatives that target health promotion with Arab
immigrant women.
51
Chapter Three
Social Dimensions of Health across the Life Course: Barriers and Facilitators to Engaging
in Health-Promoting Practices in Middle-Aged and Older Arab Immigrant Women.
Canada’s ethnocultural diversity will increase in future ageing cohorts, due largely to
increased immigration trends from non-European countries and decreased mortality rates
(Carrière, Martel, Légaré & Picard, 2016). With the increase in number and diversity of older
immigrants comes the need to attend to healthy aging in this population. Arab immigrants are
one of the largest non-European ethnic groups in Canada and immigration from Arab countries
continues to rise (Statistics Canada, 2007). Older immigrant women in Canada experience
multiple health barriers, including barriers to managing chronic illnesses, with limited access to
health-promoting resources (Guruge, Birpreet, & Samuels-Dennis, 2015). Arab immigrant
women, in particular, have minimal access to and availability of supportive health resources that
are culturally and linguistically appropriate (Aqtash & Servellen, 2013; Gholizadeh, DiGiacomo,
Salamonson, & Davidson, 2011; Girgis et al., 2009; Qahoush, Stotts, Alawneh, & Froelicher,
2010). The purpose of this study was to better understand Arab immigrant women’s experiences
of engaging in health-promoting practices as they aged in Canada, with a focus on stroke
prevention. The study used an interpretive descriptive methodology to look at the experiences of
16 middle-aged and older Arab immigrant women with making healthy lifestyle choices,
managing chronic health conditions, and accessing health-promoting resources.
The study was framed around a life course perspective to conceptualize the multiplicity
of environmental, societal, and individual factors that could influence Arab immigrant women’s
health. For this paper, we focus on findings that relate to the social dimensions of health
identified in women’s stories. Various social dimensions influence immigrant women’s abilities
52
to manage their health, such as size and quality of social networks, availability of social support,
and social roles (Grace et al., 2016; Guruge, Thomson, George, & Chaze, 2015; Kokanovic &
Manderson, 2006; Koch, Wakefield, & Wakefield, 2015; Stewart et al., 2008). We identify
transnational connections and post-migration social support as relevant social dimensions of
health influencing Arab immigrant women’s participation in health- promoting practices.
Theoretical Approach
The term ‘life course’ refers to a series of socially defined events and roles that an
individual enacts over time (Elder & Giele, 2009). Transitions, from a life course perspective,
mean the processes of moving into and out of roles and statuses across the life course (Elder &
Giele, 2009). The migration process can be seen as a major life transition, where the reasons for
migration, the context of migration, and the timing of migration impact the life course of an
individual in ways that influence health (Leu et al., 2008; Montes de Oca, Garcia, Sáenz, &
Guillén, 2011; Shishehgar, Gholizadeh, DiGiacomo, & Davidson, 2015; Spallek, Zeeb, &
Razum, 2011; Vissandjee, Desmeules, Cao, Abdool, & Kazanjian, 2004). Theoretical approaches
used to frame immigrant health issues need to reflect the ways immigrants live their lives in an
increasingly connected world, propelled by advances in technology and communication.
Evidence suggests immigrants structure their lives within transnational spaces, temporal and
spatial contexts that transcend national borders and that are shaped by processes of globalization,
capitalism, and colonialism (Calvasina, Muntaver, and Quino, 2015; Messias, 2002; Purkayashta,
2010; Gupta, 1997). A wider incorporation of transnationalism as it is shaped, disrupted, and re-
invented across the life course and the resulting influences on health is needed in the context of
migration.
53
The term “transnational spaces” is used in this paper to refer to immigrants’ continuing
ties to pre-migration contexts and the resulting impact on pre-migration and post-migration
communities in which these connections are made. Pre and post-migration contexts, respectively,
refer to the politically, historically, and socio-economically contingent realities of the countries
of origin and destination as experienced by immigrants. Transnational theoretical approaches
illuminate the complexity of macro and micro level factors across migration contexts that
influence health, the ways immigrants navigate their interests within these spaces, and the
sometimes conflicting social locations immigrants occupy across contexts (Mahler, Chaudri, &
Patil, 2015 ; Sharma & Reimer-Kirkham, 2015; Wang, & Kwak, 2015). Social dimensions of
health are often constructed within transnational spaces, revealing the fluidity, interrelatedness,
and complexity of relationships migrants maintain across pre-migration and post-migration
contexts (Carling, 2008; Viruell-Fuentes, & Schulz, 2009; Wong, 2006). We focus, in this
paper, on women’s subjective interpretations of social influences on health within different
migration contexts across the life course.
Research Design
Interpretive description, a non-categorical pragmatically-oriented qualitative
methodology, was used to allow for a process of shared interpretation between researcher and
participant, while bringing into the analysis the social, economic, and political contexts that
shape life experiences (Thorne, 2016). Interpretive Description [ID] was a method that fit well
with the theoretical approach used in this study, as it simultaneously focuses on the meanings of
experiences to participants and situates these experiences in light of broader macro and micro
level structures and processes.
54
Sample
Recruitment posters in areas with high flows of Arab immigrants such as ethnic grocery
stores, community and religious centers, and health clinics were initially used, but were
unsuccessful as a recruitment strategy. Increasing researcher visibility through engagement in
religious events and community activities over a period of one year and simultaneous use of
community gatekeepers was a successful strategy. Convenience sampling was used initially,
followed by purposive sampling later in the study. All participants were living in the community,
with 16 participants recruited altogether. Participants were Arab Muslim immigrant women
between the ages of 45 and 75, who emigrated from the Levant region of the Middle East
between 1970 and 2000, and were currently living in a major Urban Canadian center in Alberta.
Levels of education ranged from illiterate to completing junior high, with one participant having
a university level degree. Income was low to middle range with those at retirement age receiving
basic pensions. Five out of the 16 participants had a self-reported history of a health-altering
event such as a stroke, transient ischemic attack [TIA], or myocardial infarction [MI]. Self-
reported chronic disease profile included at least two cardiovascular chronic conditions and/or at
least two cardiovascular risk factors, primarily diabetes, hypercholesteremia, hypertension,
cardiac disease, obesity/overweight, and smoking. All participants were on at least two
medications for their chronic illnesses. All participants saw their family physicians every three
months to annually at a minimum. English language proficiency was mostly minimal, with all
interviews completed in Arabic or a combination of Arabic and English.
Data Collection
The Health Research Ethics Board of the University approved the research study before
initiation of recruitment. All participants chose to be interviewed at home except for one
55
interview completed in a mosque. The interview process involved a socio-demographic and
health questionnaire and a semi-structured interview. Interviews began with a broad question:
‘Can you tell me about your health?’ to allow participants initial control over the direction of the
interview. Follow-up questions touched upon a broad array of health influences, from
immigration experiences and re-settlement in Canada to recent experiences of aging with chronic
illnesses. The aim was to identify across the life course major influences on the ability to engage
in health-promoting practices. Data saturation was sought for the major themes that were elicited
in the interviews with participants. Data saturation was interpreted as obtaining data that was
both rich in the qualitative aspect of description and data that can convey commonalities and
variations of participants’ experiences. Objective health data were difficult to obtain as
participants were often unaware of their current health profile, such as blood pressure readings,
terminology of medical diagnoses, and rationale for certain prescriptions. All interviews were
audio-taped and transcribed, by the primary researcher, using verbatim transcription. A second
volunteer fluent in Arabic validated a random selection of the interview transcripts to ensure
accuracy.
Data Analysis
An ID methodology relies on constant comparative analysis processes, originating from
grounded theory, to understand human phenomena (Thorne, 2016). Cross-language researchers
have advocated for initial translation and coding to be done in the language of participants when
a bilingual researcher is available, followed by translation to English during the categorization
phase, so as not to lose cultural expressions and concepts (Temple, Edwards, & Alexander,
2006). A bilingual researcher participates in meaning construction when conducting cross-
language research, therefore the assumptions and perspectives of the researcher need to be taken
56
into account and made explicit (Temple et al., 2006).
The primary researcher was fluent bilingually in Arabic and English and had lived in the
Levant region, resulting in familiarity with language and cultural expressions. However, the
Levant region encompasses many dialects and participants were from a different generational
cohort, meaning the researcher often asked for elaboration on colloquial expressions. Data
collection, transcription, and analysis occurred simultaneously allowing for immersion into the
data over a one year period. Preliminary data analysis was done in Arabic to ensure the original
meanings of texts were not lost in translation, where initial codes and categories were located
and organized thematically. The first few interviews and resulting data analysis were translated
into English early on so that a second non-Arabic speaking researcher could identify areas
needing further investigation or possible biases in the analysis processes. An audit trail was kept
by the researcher to record details of interview contexts, changes in interviewing
questions/approaches, and thoughts on emerging categories within participants’ stories. Final
themes and exemplars were translated into English by a certified translator.
Social Dimensions of Health across the Life Course
Women in this study focused on social connections, social roles, and social support
constructed and maintained within transnational spaces across the life course. Women’s stories
revealed the continuous, linked, and non-time sequenced influences of maintaining ties between
countries of origin - the pre-migration context, and Canada - the post-migration context. Five
themes were identified that highlight socially contingent barriers and facilitators of health in the
lives of Arab immigrant women: (a) the necessity of staying strong, (b) caring for self while
caring for others, (c) double jeopardy of chronic illnesses and loneliness, (d) inadequate support
within large social networks, and (e) triple ingredients of empowerment. Some details have been
57
slightly changed in women’s stories to ensure anonymity within a small community.
The Necessity of Staying Strong
Women in this study were living with one or more chronic illness and were managing
their health in the face of multiple barriers stemming from immigration stressors, lack of social
support, and caregiving responsibilities across the life course. Staying resilient and taking charge
of their lives was a strong theme discussed by all women, who wove stories about the past to
explain current health status and approaches to health management. Women saw the strength to
be a good mother and wife in Canada as connected to positive life experiences in the pre-
migration context that fostered resilience and self-sufficiency. They often described their happy
childhood years in their countries of origin and compared it to the difficulties of migrating, often
in the context of a new marriage, and adjusting to life in Canada with economic and cultural
challenges: “…when we came here the most difficult thing was to get married and come here,
meaning a husband and wife together….there was no car , nothing…we used to live in the lower
level of my sister’s house, spread the blankets on the floor to sit on, we didn’t even own our own
bed, someone bought one for us….I used to tell my husband I want to go back to Lebanon, I do
not want to live here…” (Participant 12). Usually the adjustment phase was followed by finding
economic stability, developing a sense of belonging in Canada, and focusing on their roles as
mothers and wives, resulting in a sense of accomplishment and pride in older age: “ …If we
wanted wars and headaches we could have stayed home in Lebanon, we ran away from this to a
decent life, right, to start and have a decent family, we came here, thank God, we worked so
hard, we raised our kids and we raised beautiful kids…” (Participant 7) Positive stories were
often connected to more positive attitudes towards health alterations and a stronger sense of
control over health.
58
Other women experienced difficult childhoods due to war, economic disadvantage, and
lack of education opportunities. These women constituted a cohort that grew up in a period when
education was not readily available for girls and marriage in the teenage years was a norm.
Traumatic life experiences such as witnessing violence, death of a parent, or poverty in
childhood were connected in women’s stories to negative perceptions of health and difficulty
managing health concerns. The early death of one woman’s mother and her subsequent
mothering role for younger siblings was drawn upon to describe her perception of current mental
and physical illnesses: “…I grew up without a mother, I came here and life was difficult…My
husband was working at the grocery store then he would go out to party with friends…I was the
man and the woman in the house…I suffered a lot.” (Participant 8). Women who were most
vulnerable as aging immigrants in Canada often told stories that reflected ongoing hardship and
disempowerment across the life course, such as poverty in childhood, lack of education, war, and
difficult marriages.
Caring for Self while Caring for Others
Transnational connections were explained by women as ongoing social ties to pre-
migration contexts. The majority of women in this study migrated in their late teens to early
twenties. As the women became more economically and socially stable in Canada, usually in
mid-life, they were more involved in supporting family in the pre-migration context and this
support continued as they aged. Support was described as financial assistance to family,
intermittent caregiving for elderly parents, and solidarity with Arab political struggles. Providing
support often was a barrier to women’s abilities to manage health, especially in times of family
crises. Despite knowing that self-care was important, women often prioritized the needs of the
family. Important here was that family responsibilities and loyalties extended across borders
59
necessitating periodic travel and economic sustenance, plus precipitating an ongoing sense of
worry towards global political, social, and economic realities that affect the well-being of family
in other places.
These women came from a region marred by economic and political unrest that ebbed
and flowed over their life course. At the time of the interviews, events such as the Arab Spring,
the Palestinian Intifada, and the Syrian Uprising were ongoing concerns for the community: “The
whole Arabic situation is tragic, after I watch the news my blood pressure increases…sometimes
I watch about Palestine and I stop, I stop, my heart, my blood pressure increases.” (Participant
4). One woman correlated her political activism with the onset of a cardiac event: “I went to a
rally for Gaza, next day I had a heart attack, I feel the people’s pain; it was a stressful summer.”
(Participant 3). Supporting family in the country of origin also entailed financial assistance:
“You are not only supporting your family here, but your family back home too.” (Participant 3).
In further elaboration, this woman stated: “My brother has health issues in (home country) and
we all feel guilty that he is alone…we help with money…I was worried that day about him.”
Women’s abilities to engage in health-promoting behaviors were also diminished due to
caregiving role strains and lack of assistance with household responsibilities. Women’s
caregiving roles began at an early age as mothers and wives and continued in caring for ill
spouses, ageing parents, and grandchildren. In discussing her spouse’s illness and her role as a
caregiver, one woman stated: “Things passed…but if I get a second stroke I will not be surprised,
there was a lot of pressure.” (Participant 12). A second woman reflected on her caregiving role:
“what makes it difficult is when he gets sick, I stop taking care of myself, I worry about him and
forget myself.” (Participant 7). She later elaborates: “I was fine with my exercise, after my stent,
I started with this senior program three days a week and I was doing good…until he had his heart
60
attack and then I was too busy with him, I was always scared to leave him and go…” In referring
to the double stressors of caring for her father living in her home country during a terminal
illness and her responsibilities towards her children a third woman said: “From that event…to
now, is the period where my health was most affected…sometimes I do not get enough sleep…if
a child speaks to me I do not have the desire to answer, I do not have the desire for anything…”
(Participant 5). One woman described stopping her medication when she traveled to her country
of origin to care for her father and attributed this as a potential cause for her stroke: “I lost half
my body weight, I was not eating…I stopped taking my medication…I kept working and stayed
beside my mother, may her soul rest in peace, I did not leave or go out or walk…at home…you
see misery/sadness and staying at home all the time made it worse.” (Participant 6)
Double Jeopardy of Chronic Illnesses and Loneliness
Women coped effectively with chronic illnesses and/or the residual effects of a health-
altering event when strong social support was present in their lives. Women described social
support as having close friends they could confide in, having social activities outside the home,
receiving financial help and services from family, and being connected to community and
religious organizations. When women experienced multiple vulnerabilities, such as decreased
social support, caregiving role strains, family crises, and stressors from transnational
connections, they reported experiencing more emotional and mental distress and, subsequently,
decreased ability to manage health effectively.
Loneliness was a re-occurring term used by women with multiple vulnerabilities to
describe their situation at the time of the interview. Two quotes that exemplified the feeling of
loneliness well were: “For the person sitting quiet at home, do you speak to the walls, you listen
to the television but you want to speak too.” (Participant 13) and “Here (referring to Canada) is
61
being in prison without having committed a crime…in Lebanon you can put the chair on the
balcony and hear the cars go by…here is a place full of people but it is empty.” (Participant 10).
This last quote came from a woman who had significant physical limitations and minimal social
support resulting in her being confined to the home the majority of the time. Loneliness was
exacerbated in this group by a feeling that children were busy with their own lives, death and
disability within peer cohorts in Canada, weakened ties to social networks in countries of origin,
need to save face within the community by concealing problems, caregiving responsibilities, and
chronic illnesses that limited mobility and stamina for social interactions. One woman whose
spouse recently passed away stated: “I have a little bit kind of depression, I am alone….I have
very nice children…they check on me, they call me, they have supper with me but not every day
and they are busy too…” (Participant 10). Another woman said: “there are people who are
disabled, who cannot drive…another person, if they can, should come every two weeks and say
hello, how are you.” (Participant 16)
Inadequate Support despite Large Social Networks
Women consistently pointed to the lack of support in managing chronic illnesses and
engaging in health-promoting practices as one of the biggest barriers to health. Lack of support
was described as lack of information about ways to engage in health promotion, lack of
emotional support in managing emotional and mental health consequences of their illnesses, and
lack of access to community and health resources that are culturally and linguistically sensitive.
Women’s social networks were often consolidated within the same ethnic and linguistic
community, making it difficult to access support within the wider Canadian context. Women
described accessing different forms of social support in their lives from family, friends,
neighbors, and community acquaintances to varying degrees of satisfaction.
62
The majority of women did not want or felt they could not burden family members with
their health concerns and attempted to hide their emotional and mental distress when present.
Children were seen as having their own lives and being too busy to provide needed assistance: “I
go to the mall and walk a bit and when I am tired I sit down, but to my children I say nothing, I
say I am good…I don’t want them to worry about me.” (Participant 6). Women found their
friends within the same age cohort as vital in countering the negative effects of life stressors:
“what helped were my friends, my friends more than my kids, because my kids for example ask
how dad is. ‘How is dad doing?’ Dad, dad, I tell them, I see you are asking about your father all
the time but I am the one suffering.” (Participant 12). Yet, at times, their mental/emotional state
hindered socialization and in turn exacerbated expressions of frustration and anxiety. When
asked about opportunities for socialization, one woman indicated: “I don’t have (referring to
social engagements)…I get bored…10 mins to half an hour and I say take me home again, I no
longer have patience even with myself.” (Participant 8) This same woman complained about
frequent headaches attributed to staying home all the time and not being able to drive.
Some women identified external barriers to socialization. Extensive social networks
when present, did not always interpret into emotional support and companionship: “I do not have
a lot of friends, but I know everyone…” (Participant 2) and “I got to know a lot of people when I
came to Canada, but only a few turned out to be my truest friends.” (Participant 6). Many women
felt they could not confide their personal troubles to people from the community as it was
important to save face and avoid gossip or people were too busy with their own lives:
“Nowadays everyone has their own problems…you cannot bother others, every day there is
work, many worries, responsibilities of children, responsibilities of the home…” (Participant 16).
Another woman’s story reveals the complex ways lack of social support can materialize in the
63
lives of immigrant women:
Once I stood on the sidewalk and waited for a lady from the community to pass and told
her you have to come drink a cup of coffee…she came, maybe when she knew who I was
and where I was from she didn’t visit any more…everyday she goes walking with her
friend or her neighbor, I never saw her at my place and she didn’t invite me to hers.
(Participant 4)
In an ethnically rich neighborhood the divide between different Arab groups on political, class,
and religious lines hindered socialization and exacerbated loneliness for this woman. The sense
of exclusion was exacerbated by being new to the neighborhood, having come from another
province. Language barriers prevented her from getting to know her English-speaking neighbors:
“My neighbor has children, non-Arabs, maybe because of language we don’t talk, I don’t say
hello, how are you, they think I am different…If I could speak the language, I would talk to
her…we have been here a year.” (Participant 4)
Triple Ingredients for Empowerment: Faith, Language, and Driving
Women referred to three ingredients: (a) faith, (b) speaking English, and (c) ability to
drive as facilitators of health. Women who described themselves as healthy could drive and had a
better command of the English language. They were more able to, independently, seek out
opportunities to counterbalance loneliness and incorporate health-promoting activities into their
daily routines through volunteering, working part time, going to malls for walks, gardening, and
visiting with friends. Having a basic command of the English language and driving both
increased opportunities for socialization with non-Arab neighbors and participation in wider
community activities. When absent, a negative cycle ensued where, for example, women could
not access English language lessons since they could not drive. They could not access avenues
64
for social support within the wider English-speaking community due to language barriers that
exacerbated a sense of difference and isolation.
English fluency and ability to drive were determined largely by re-settlement in the early
post-migration context. Often work outside the home involved labor work or family businesses
which offered little opportunity for socialization in English. For the majority of women access to
English as an additional language [EAL] was hindered by childcare responsibilities, lack of
support from family members, and transportation difficulties: “I said I want to learn (to become
literate) and go to school. I would go 8 in the morning and finish at 2 pm and then return to
work. I would finish work 6, 7, or 8 pm and come home. You have to cook, you have to clean,
there are kids, and my husband is at home with an injured hand, anyway, what I could do. I
learnt a little and felt I wasn’t benefiting. Everyone else was advancing in class but I did not have
time to study. I would come home and need help but there was no one to help me. So I said I am
not going any more…I removed education from my plans…” (Participant 9) and “I studied at
(name of immigrant women service organization). I went and bought books…my son was a
baby, I got a babysitter, he kept crying, I would go home and find my four children unhappy…in
the end I learnt a little from television, from life.” (Participant 1). Driving, on the other hand,
was often seen as a pressing necessity due to spouses working out of town and/or the need to
take children to appointments and run errands: “I go visit people, friends, run errands, if my
husband can’t drive, he is sick, I take him to the doctor…driving is very helpful for a woman,
especially in this country.” (Participant 13) and “…the thing that helped me make life easy for
both of us is he pushed me to drive…One time I had an appointment with the doctor and he
forgot, so I called him at work and said we have to go to the doctor and he said that’s it, you are
going to drive.” (Participant 7)
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Women saw staying close to God using prayer, learning about their religion, and
attending religious events as helping them build intrinsic coping abilities in the face of life
stressors. In describing the experience of caring for a critically ill spouse, one woman shared her
perspective: “They say if you have a problem you should confide to someone. Despite friends
visiting I used to share very little….my problem I confided in God and complained to him and I
ask why it is this way Oh God?” (Participant 12). Religious teachings provided women with
fatalistic notions of illness and health altering events, where things were seen as being as God
destined them to be. Yet, this perception was balanced with Islamic teachings that emphasized
personal responsibility for one’s health, not giving up hope, caring for the body, and seeking
treatment. After a health-altering event or life crisis, women described their experiences of
connecting to God to gain the strength to manage health effectively. Praying and reading the
Quran were seen as effective stress management strategies. A woman described the impact of
faith on overall wellness: “Faith helps you feel healthier, stronger, whatever happens to you, you
say ‘thank God’ and if something happens to you, you don’t cry over it…” (Participant 7)
Discussion
Women with multi-layered vulnerabilities described mental and emotional distress,
loneliness, and unmanaged chronic illnesses such as diabetes and hypertension. Being an older
Arab immigrant woman with chronic illnesses did not, however, consistently interpret into high
levels of vulnerability. Some women in the study were able to navigate and access different
levels of social support and foster personal resilience to manage their health effectively.
Vulnerability here is used to reference women who experienced various barriers to engaging in
health-promoting practices, minimal access to supportive resources that facilitate health, and
who reported dissatisfaction with their health status at the time of the interview. We focus on
66
transnational connections and post-migration social support as being key social dimensions of
health influencing the ways vulnerability can manifest in the lives of Arab immigrant women.
Maintaining Transnational Connections across the Life Course
The findings around ‘the necessity of staying strong’ and ‘caring for self while caring for
others’ show the influences of social roles and caregiving responsibilities on women’s abilities to
care for self and manage health concerns effectively. For the women who had arrived as young
adults and lived the majority of their lives in Canada, it might be expected that the post-
migration context be most influential on health. The three migration contexts- pre-migration,
migration, and post-migration- were not mutually exclusive in women’s stories. Rather a fusion
of spatial and temporal connections across contexts was the main insight gained from women’s
experiences. The ‘there’ and ‘here’, and the ‘now’ and ‘then’ were interconnected to create
unique and tangible influences in women’s lives, particularly in their abilities to manage health.
Transnational connections were framed as women’s emotional ties to loved ones in the home
country, material assistance in the form of remittance, and intermittent caregiving for children
and parents. The literature on transnational ties reveals that these connections across the life
course can serve to either enhance well-being or increase stress depending on a variety of pre and
post migration factors (Amoyaw & Abada, 2016; Sanon, Spigner, & McCullagh, 2016; Torres,
Lee, González, Garcia & Haan, 2016).Women in this study often described the cumulative
impact of ongoing caregiving roles transnationally and locally as resulting in physical and mental
exhaustion and subsequent disregarding of personal health needs.
Despite strong transnational ties in this study, women often described feelings of
loneliness as they aged in Canada, raising questions about reciprocity in continuing transnational
ties in the post-migration context. Loneliness can be defined as a subjective sense of emptiness,
67
worthlessness, lack of control, and personal threat (Cacioppo, Hawkley, & Thisted, 2010, p.2).
Immigration as a factor that influences loneliness continues to be an important area of study with
some indication that timing of migration in an individual’s life (Wu & Penning, 2015), the
quality of social networks, (De Jong Gierveld, Keating, & Fast, 2015), and belonging to an
ethnocultural minority ( De Jong Gierveld, Van der Pas, & Keating, 2015) influence the
development of loneliness. Women in the study who had low income, mobility limitations,
minimal English fluency, and who reported mental and/or physical health problems were more
likely to report feeling lonely.
Availability of Social Support in the Post-Migration Context
The findings around ‘double jeopardy of chronic illnesses and loneliness’ and
‘inadequate support within large social networks’ point to limited social support in the post-
migration context in relation to engaging in health-promoting practices. Social relationships in
the post-migration context were described as being part of a broad social network within the
Arab community but, also, as having limited social support in managing health. Social support
refers to the psychological and material resources a social network can provide to buffer life
stressors (Cohen, 2004). Cohen defines three forms of social support: (a) instrumental, involving
financial or task-oriented assistance, (b) informational, involving relevant information or advice,
and (c) emotional, involving caring and empathetic behavior. Social support impacts health by
constituting a stress buffer or what we term a facilitator of health, where perceived support helps
facilitate positive cognitive processing of stressors and actual support facilitates successful
coping strategies. These three forms of social support were addressed in conversations with the
women. Having an extensive Arab social network or living in a neighborhood with a high
percentage of Arabs did not necessarily interpret into social support due to possibilities for
68
exclusion based on other categories of belonging, mobility issues that limit ability to interact
with others, and need to save face when dealing with life stressors. Peers were seen as essential
for companionship and emotional support, but family problems and personal issues were often
concealed to save face and avoid gossip, meaning these women did not have ways to vent
negative emotions. Women’s families, especially their children, were the primary sources of
informational and material support in the context of managing chronic illnesses and engaging in
health promoting activities. Forms of support provided by family were often seen as inadequate
due to lack of services specifically targeting the needs of Arab women, limited family financial
resources, and unwillingness of women to burden family with their needs. Immigrant women
might focus on co-ethnic social relationships for support due to limited fluency in English
language, lack of workforce participation, or restricted opportunity for socialization within the
wider community (Hynie, Crooks, & Barragan, 2011; Neufeld, Harrison, Stewart, Hughes, &
Spitzer, 2012; Stewart et al., 2006; Wong, Yoo, & Stewart, 2005), despite this support not
always meeting their needs. Also, immigrants from common ethnic backgrounds can differ in
their historical and social positioning leading to a sense of difference, lack of solidarity, and
loose social ties within social networks in the post-migration context (McMichael & Manderson,
2004). The findings in this study mirror those in the literature on other immigrant groups where
social networks within the same ethnic group and proximity of family in the post-migration
context do not necessarily interpret into the required quantity and quality of social support.
The literature shows that older adults migrating in later life tend to lack opportunities for
social integration and face language and cultural barriers that influence health negatively (Chun
et al., 2011; Emami & Torres, 2005; Tummala-Narra, Sathasivam-Rueckert, & Sundaram, 2013).
This study also points to challenges when migration occurs early in life and women are aging in
69
Canada while experiencing multiple vulnerabilities. In the findings, women identified ‘triple
ingredients for empowerment’, where English proficiency, ability to drive, and religiosity were
factors highlighted by women as enhancing intrinsic coping and access to social support.
Speaking English meant increased knowledge of and comfort accessing community and health
services. Driving and owning a car were essential for socialization, access to health services, and
for maintaining a sense of independence with increasing age. Religiosity enhanced intrinsic
coping but also served to increase social connectedness and access to social support via mosques
and religious activities. Providing English as an additional language [EAL] learning
opportunities, facilitating access to transportation, and incorporating spiritual dimensions of
health into health promotion initiatives are all important avenues for future exploration in
supporting Arab immigrant women in managing health concerns.
Conclusion: Limitations and Implications
Participants in this study chose to focus on aspects of their lives that they perceived as the
most stressful and that hindered attempts to engage in health-promoting practices. Immigration
to Canada is expected to increase, people are living longer, and the burden of chronic diseases is
expanding. The margins between local and global will continue to dwindle necessitating new
ways of conceptualizing immigrant health. A strength of this study is that it provides insight into
the ways transnational connections create health barriers and facilitators across the life course.
The need for expanding initiatives that provide opportunities for socialization to gain peer
support, exchange knowledge, and access recreational activities and the positive impact such
activities can have on health, especially in vulnerable isolated older adults from minority groups,
has been addressed in the literature (DiGiacomo, Green, Rodrigues, Mulligan, & Davidson,
2015; Stewart et al., 2006). This study points to the need to incorporate into such initiatives an
70
understanding of stressors created by social connections locally and transnationally.
A limitation of this study was the small sample size and the restriction of recruitment to
two urban community/religious centers. In speaking to community gatekeepers, we were told the
most vulnerable women were difficult to access due to limited mobility and restricted
opportunities for socialization within the community. This warrants further work on methods of
accessing isolated older Arab immigrant women. Also, the open ended nature of the interview
meant women chose to focus on aspects of their illness that were of most concern to them at the
time, raising the question of other factors across the life course that were not shared in the
interview process. Overall, this study points to the utility of framing immigrant health from a
transnational life course perspective. Moving forward it is necessary to attend to life course
influences on health across migration contexts within research initiatives, nursing practice, and
policies that focus on immigrant women.
71
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Chapter Four
Title: An Intersectional Exploration: Experiences of Stroke Prevention in Middle-Aged and
Older Arab Muslim Immigrant Women in Canada.
Authors: Jordana Salma, Kathleen, F. Hunter, Linda Ogilvie, Norah Keating
Journal: Journal of International Nursing Studies
Status: For future submission
Abstract: Arab immigrants living in the West have higher rates of stroke and uncontrolled
stroke risk factors, more debilitating stroke events, and less knowledge and resources for stroke
prevention in comparison to other immigrant and non-immigrant groups. Arab immigration to
the West is increasing, yet there is a dearth of research addressing the experiences and needs of
this population in the area of stroke prevention. This paper presents an interpretive descriptive
study to understand experiences of practicing stroke prevention, with a focus on managing
chronic illnesses that increased stroke risk, making healthy lifestyle choices, and navigating
access to healthcare resources. Sixteen middle-aged and older Arab Muslim immigrant women
were recruited between 2015 and 2016. Study themes relate to weaving a narrative to explain
chronic illnesses, pursuing knowledge in the dark, negotiating medication and treatment options,
making an effort to eat healthy and be active and navigating access to health resources. A
transnational intersectional lens is used to highlight structural barriers to health and to address
discourses that serve to reinforce barriers and hinder efforts to improve health.
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Chapter Four
An Intersectional Exploration: Experiences of Stroke Prevention in Middle-Aged and
Older Arab Muslim Immigrant Women in Canada.
Stroke is a leading cause of death worldwide (World Health Organization, 2014), with
the risk of stroke doubling every 10 years after the age of 55 (Public Health Agency of Canada,
2009). Women tend to have greater post-stroke disability and poorer recovery in comparison to
men, which is partly explained by older age of stroke onset, poorer pre-stroke functional status,
multi-morbidities, and poorer social support (Appelros, Stegmayr, &Terent, 2009; Persky,
Turtzo, & McCullough, 2012). Arab populations and Arab immigrant groups living in Western
nations have increasingly higher rates of uncontrolled stroke risk factors (Benamer & Grosset,
2009; Tran, Mirzaei, & Leeder, 2010), more debilitating stroke events (El-Sayed, Tracy,
Scarborough, & Galea, 2011), and less knowledge and resources for stroke prevention (Ali,
Baynouna, & Bernsen, 2010; Gholizadeh, DiGiacomo, Salamonson, & Davidson, 2011) in
comparison to other immigrant and non-immigrant groups. Yet, there remains a dearth of
research on stroke prevention and management approaches in Arab populations (El-Sayed &
Galea, 2009; Musaiger & Al-Hazzaa, 2012).
Little is known about Arab immigrant women’s experiences of managing health in the
context of stroke prevention. In this paper, we discuss results of an interpretive descriptive study.
Sixteen middle-aged and older Arab immigrant women were interviewed to understand
experiences of engaging in health-promoting practices in the context of stroke prevention. The
study addressed both primary and secondary stroke prevention practices involving managing
chronic illnesses that increased stroke risk, making healthy lifestyle adjustments, and accessing
supportive health resources. Results center on five themes: (a) weaving a narrative to explain
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chronic illnesses, (b) pursuing knowledge in the dark, (c) negotiating medication and treatment
options, (d) making an effort to eat healthy and be active, and (e) navigating access to health
promoting resources. We use an intersectionality approach to analyze the results of the study
with a focus on social structures and practices that influence women’s abilities to manage health
effectively.
Theoretical Approach
Intersectionality, a term first used in the work of Patricia Hill Collins (1999) and
Kimberle Crenshaw (1991), recognizes the influence of multiple social locations in creating
patterns of privilege and oppression within spatially and temporally constructed realities.
Intersectionality approaches incorporate other dimensions of social identity into the study of
gender, by examining the inter-relatedness of social categories, the operation of power in the
formation of social categories, and the resulting lived realities of those who inhabit multiple
social locations (Dhamoon & Hankivsky, 2011; Vissandjee & Hyman, 2011; Shields, 2008).
Intersectional approaches can be used in immigrant women’s health research to illuminate micro
and macro structures of power that operate in women’s lives within the unique social spaces that
they occupy (Doyal, 2009; Sen, Iyer, & Mukherjee, 2009; Veneestra, 2011). Social identities and
positions are not seen as static, essential to a group or inherent qualities of a person but rather are
emergent, fluid, and contingent on hegemonic and micro operations of power (Anthias, 2012).
Immigrant research can suffer from what is termed “domestic intersectionality” (Gupta,
1997; Patil, 2013), a failure to examine the interactions between international and regional forces
and the resulting influences on local realities. Immigrants rarely live in the confines of the nation
state to which they immigrate, but are more prone to structure their lives and see themselves
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within spatial and temporal contexts that transcend national borders (Bustida, Browns, & Pagan,
2008; Calvasina, Muntaver, and Quino, 2015; Purkayashta, 2010). In immigrant health research,
analyses of social, historical, and political processes within and across nation states are necessary
to understand the factors that shape health outcomes and experiences. Data collection and
analysis for this study were completed with the aim of illuminating influences on women’s
everyday lives but, also, with a pragmatic question of what could be done to effectively support
women in managing their health. Here, we begin with describing the personal experiences of
women and move to examining the ways these experiences were shaped by structures and
processes that serve to limit or facilitate effective stroke prevention strategies.
Research Design
Research Methodology
Interpretive Description [ID] is a non-categorical qualitative methodology that is used to
understand subjective experiences related to phenomena of interest to nursing practice (Thorne,
2016). Interpretive Description focuses on knowledge development using a combination of data
collected in the practice field, prior knowledge in the area, and abstract theorization. The
methodology involves inductive reasoning to move from a description of observed phenomena
relating to human experiences to identifying patterns of experiences, to then searching for the
meaning of these patterns within the context of their occurrence.
Sample
Recruitment involved increasing researcher visibility through engagement in religious
events and community activities over a period of one year and simultaneous use of community
gatekeepers to identify potential research participants. Recruitment posters increased community
awareness of the study. Convenience sampling was used initially, followed by purposive
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sampling to follow up on themes that required further investigation. Thorne (2008) argues that
sample size depends on whether sufficient data have been collected to render the question
answerable in a way that informs practice. Data saturation was interpreted as obtaining data that
was both rich in the qualitative aspect of description and data that conveyed commonalities and
variations of participants’ experiences.
Sixteen community dwelling middle-aged and older Arab immigrant Muslim women
from the Levant region were recruited altogether. Ages ranged from 45 to 75 years with
immigration occurring in young adulthood for all except three who immigrated later in life. All
participants saw their family physicians regularly, at least every three months or more. Tables 1
and 2 outline participants’ health profiles and additional socio-demographic information. Seven
out of the 15 women explicitly stated they were on low income government assistance, but
yearly income was inaccessible for other women.
Table 1: Health Information
Participant Data (total=16)
One or more self-reported chronic
illness*
14/16
One or more self-reported stroke
risk factors**
16/16
Occurrence of health-altering
event (stroke or transient ischemic
attack, myocardial infarction)
5/16
One or more medications to
manage chronic diseases/risk
factors
14/16
* Chronic health conditions: hypertension, diabetes, cardiac disease, arthritis
** Stroke risk factors: sedentary lifestyle, smoking, obesity/overweight
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Table 2: Socio-Demographic Information
Participant Data (total=16)
Marital status Married widowed
13 3
Living arrangements With family Alone
15 1
Occupational history Housewife Outside home employment,
including running family
businesses
10 5
Education None(illiterate) elementary to junior
high
Post-secondary
4 11 1
English fluency None Minimal(functional) fluent
9 6 1
Income Unable to gather due to difficulty obtaining disclosure
Data Collection
The health research ethics board of the university approved the research study before
initiation of recruitment. All participants chose to be interviewed at home except one who was
interviewed at a mosque. Interviews commenced mostly in Arabic. Health data collection was
based on personal reporting and participants were often unaware of particular aspects of their
health profile such as blood pressure readings, terminology of medical diagnoses, and rationale
for certain prescriptions. All interviews were audio-taped and transcribed by the primary
researcher, using verbatim transcription. A second volunteer fluent in Arabic validated a random
selection of the interview transcripts to ensure accuracy.
Data Analysis
An ID methodology relies on constant comparative analysis processes, originating from
grounded theory, to understand human phenomena (Thorne, 2008). Preliminary data analysis
was done in Arabic to ensure the original meanings of texts were not lost in translation, as Arabic
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words and expressions can have multi-layered conceptual meanings which are not easily
translated into English. The first few interviews and preliminary data analysis were translated to
English early on so that a second non-Arabic speaking researcher could identify areas needing
further investigation or possible biases in the analysis processes. Final themes and exemplars
were translated into English by a certified translator.
Experiences of Engaging in Stroke Prevention Strategies
The study results center on five themes: (a) weaving a narrative to explain chronic
illnesses, (b) pursuing knowledge in the dark, (c) negotiating medication and treatment options,
(d) making an effort to eat healthy and be active, and (e) navigating access to health promoting
resources.
Weaving a Narrative to Explain Chronic Illnesses
Women’s experiences of being diagnosed with a chronic illness or suffering a health-
altering event were connected to experiences of loss, sadness, or crisis. Often women identified
significant life events as having a direct impact on their well-being, especially when those events
related to the well-being of their children. One woman, in narrating a story of her son’s divorce,
stated, “From then on the problem developed, I got high blood pressure, high cholesterol, and I
started from that time to take blood pressure medication. I was okay before that, after this too
much stress.”(Participant 13). When asked about the cause of her diabetes, a second woman
replied, “It came from sadness, because I have no family history, it came from sadness. I was sad
about my eldest daughter and I got diabetes from crying and being sad. I was dizzy, and they
took me to the emergency. They didn’t know it was diabetes and then they knew. Life’s stressors
are hard…” (Participant 2). While another woman who recently had a stroke and was grieving
the recent death of an adult child stated, “I feel misery inside me, I feel tired always, tired. There
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is not one day I get up and my head is calm.…the first year the boy died I lost lots of
weight…from then on the high blood pressure started, it all started (referring to health
alterations)…from that point I started to take medication for my blood pressure.”(Participant 6).
These life stressors at times had psychological and emotional implications, where women
described experiencing symptoms such as chronic headaches, insomnia, anxiety, and
restlessness, as indicated in the following quotes, “This is life and I get very nervous, anxious,
people used to say I speak shouting, but I don’t think I do…” (Participant 8), and “I now go to
sleep but I am not sleepy, all the troubles come to you when you have your head on the
pillow…” (Participant 10). These symptoms were only reported to physicians when severe, but
were not described by participants in terms of mental illness. Rather, women saw the stressors in
their lives, their chronic illnesses, and their mental and emotional states as inter-related and
counter-influencing.
Pursuing Knowledge in the Dark
The majority of women in this study who had stroke risk factors, such as diabetes and
hypertension, were not aware of the signs and symptoms of a stroke, even when they knew about
their high risk profile, “Strokes, I know nothing about it, but I hear people say this person had a
stroke, that person died from a stroke….they say it relates to blood but I don’t know.”
(Participant 2) Many women lacked knowledge in crucial aspects of managing their chronic
conditions and preventing potential complications, “He (doctor) said your blood pressure is a bit
high. What the symptoms are, what I should eat, what I should do, I don’t know….I need more
information about diabetes and high blood pressure.”(Participant 4).
The five women who had experienced a health-altering event described themselves as
being caught off guard, unaware of their risk profile. A woman stated, “I never imagined that a
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heart attack can happen because I am walking, do not eat fatty foods or have high cholesterol…
heart attack came from nowhere.” (Participant 3). A second woman said:
I told all my doctors that I exercise and I am worried about if I should stay at home and
stop exercising, why did this happen to me? I do all this exercise and I still got a stroke,
so from now on I do not want to exercise. They (doctors) answered wait, wait, if it wasn’t
for the exercise you wouldn’t be as good as you are now. (Participant 12)
Generally, women spoke positively about their experiences with family physicians and
saw them as a supportive resource in managing their health. Women who had limited English
proficiency looked for doctors who spoke Arabic or had family members accompany them to
appointments. Lack of physician time and limited English proficiency were main factors
hindering access to information, as exemplified in the following two quotes, “Doctors are not
giving attention like before and they are all in a hurry…” (Participant 13), and “They are very
good, they give attention and are calm….doctor is Libyan because we are not strong in English,
meaning if I answer in English wrongly I would not benefit.” (Participant 11). Family doctors
were primary sources of health information. Often women were told about lifestyle changes
needed, such as stopping smoking, more exercise, or diet changes by their family doctors but
they were left to their own devices in discovering how to manage doing this. Arabic internet
sites, for those who were computer literate, and television programs were sources of health
knowledge as well. One woman who was an active community member stated, “I think they
(women in the community) need someone to tell them, like lectures here, and tell them the cause
for diseases, something like that.” (Participant 12).
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Negotiating Pill Taking and Treatment Options
Women generally viewed taking medication negatively. They described attempts to stop
their medication or decrease dosages, sometimes without consulting their physicians. Lack of
symptoms was often interpreted as not needing to take medication. Women also had conflicting
emotions when physicians prescribed medication they thought was unnecessary or when the
medication failed to manage their symptoms effectively. This either led to conflict with
physicians or led to women discreetly stopping medication or adjusting dosages. After
experiencing a stroke at a young age one woman discussed her decision to stop prescribed
preventive medication, “…when I got better I said I don’t want to take it, I hate medicine, I don’t
want my body to get used to medication” (Participant 10). Another woman showed the
interviewer a bottle of pills, “Medication for my bones. I have not taken it for three months. I
want to give my body a rest from them….the white pill bothers me, you have to take it and not
eat cheese and not eat yogurt while all my diet is made of cheeses…” (Participant 2). Reluctance
to start medication newly prescribed was noted as well, “Sometimes I leave it (medication) for
two months without buying it, sometimes I buy it and put it in the closet, I take it for a few days
and stop taking it, why? What do I need it for?” (Participant 7)
Travel, financial pressures, and heightened caregiving strains were noted in some cases as
a likely time for decreased medication adherence. Women felt taking medication was
cumbersome, unnecessary, or thought that giving their bodies a rest would be beneficial:
It all costs money, expense on us, I told the doctor I want to stop some of the medication
he said no, no, no you cannot stop medication. When I went to the hajj (Muslim
pilgrimage to Mecca) I stayed three months without taking anything. Thank God I was
okay. When I returned from the hajj I told the doctor I stopped the medication for three
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months. He said you are crazy He is Canadian…tomorrow you will have strokes or heart
attacks or something so I started taking them again. (Participant 14)
Many women had limited health coverage beyond their public health insurance, which in
Canada covers mostly acute and emergency healthcare needs. Even the small amount of money
required to cover costs of medication and treatments in the community was a considerable
financial strain. When asked about diabetic foot care one woman answered, “Sometimes I go and
they take 65 dollars….I used to go to the doctor and don’t go any more. He used to scrub them
for me and fix them but I didn’t go again. I do them at home.” (Participant 2). One woman said,
“Everything is expensive for us….They used to help pay for diabetic pills but they
stopped…They don’t pay for these anymore. A diabetic test strip costs a dollar…” (Participant
14). A third woman stated: “I think with old age pension they should give people a little more,
what they give is not enough.” (Participant 7) Women’s stories pointed to the reality of access
disparities within a public health system and this was exemplified in one woman’s worry about
taking a drug that requires frequent blood testing over a drug that was costly but more lifestyle
friendly:
They prescribed a blood thinner and said your health insurance does not cover the costs
of the blood thinner, so I asked what do you mean? They answered that there are two
kinds of blood thinners; one requires a blood test weekly and one doesn’t but the one that
doesn’t you have to pay for. I started to cry. My husband’s income is not enough. I can
ask for help from my children as they are in good financial situations but I don’t want to
ask them for help with everything… (Participant 15)
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Making an Effort to Eat Healthy and be Active
Lifestyle changes such as diet and exercise were the most discussed issues in the context
of stroke prevention. Healthy eating was considered crucial in maintaining overall health and the
women tried to focus on making healthy choices. Unhealthy diets were defined as eating too
much and diets high in fat and animal protein, “I treat myself…my body gives me the
information…I watch what I eat, if something bothers me I avoid it.” (Participant 16), and “when
I watch what I eat I feel there is a difference…this is what is protecting me from gaining a lot of
weight.” (Participant 8)
There was a lack of information for many women on specific restrictions and
modifications related to chronic illnesses such as diabetes and hypertension, even after seeing
dietitians. In referring to a visit from the dietician one woman stated, “…she knew all the dishes
(Lebanese)….she told me I shouldn’t eat these dishes. She said you can eat tabbouleh without oil
or salt (laughs). What kind of tabbouli (Lebanese salad dish) that would be? I told her okay…I
did not adhere to her recommendations but I decreased my salt intake.” (Participant 12), and a
second commented, “ …sometimes I eat potatoes and everything and my sugars are four (low)
and sometimes I find my sugars are 15 (high), like yesterday, I don’t know, something is wrong,
something is wrong with my body…”(Participant 2)
Healthy eating was something the women reportedly managed better than physical
activity. Most frequent physical activity described was walking and housework. The difficulty
with maintaining adequate physical activity levels was related to chronic pain and mobility
issues and lack of familiarity with ways to modify exercise appropriately, as exemplified in the
following quotes, “I would like to walk, when I walk a little my back hurts…” (Participant 7),
and “…I get up to the kitchen and do a thing or two, then my back hurts and I sit on the chair.
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This is not movement. Housework is tiring. It is not exercise. What to do…” (Participant 1).
Household obligations such as cleaning and cooking, and caregiving roles left women feeling
they had little time for exercise. Transportation issues, weather, and difficulty finding culturally
appropriate exercise facilities were other cited concerns, “I am not good at exercise. I exercise at
home running here and there, I don’t sit…I walk in the house a lot, go up and down the
stairs…to exercise where they do exercise I find men there and such…” (Participant 5).
Navigating Access to Health Resources
Transnational ties to countries of origin facilitated access to traditional remedies and
medical treatments in the countries of origin. This access relied heavily on social networks
within countries of origin to learn about new treatment options, locate competent physicians, and
procure medication not readily available in Canada. Women often used Arabic and Islamic
traditional remedies, but this did not, in most cases, hinder the use of medical treatments
prescribed by doctors in Canada. Many women commented on the practice of bringing herbs,
spices, and remedies from the home country to use in Canada, “I do not buy herbs from here,
never, we have (mashallah) in the home country a market where the herbalist will prescribe a
remedy…when I came I brought the herbs with me…” (Participant 10). The use of traditional
remedies, however, usually related to mild health concerns or symptoms that were not being
managed well as shown in the following quotes, “If I tell you I have a sore throat, I go and boil
some herbs, because if I go to the doctor he will say nothing wrong…” (Participant 13), and
“…the Quran tells you that the (habit l barakah) and about honey and about vinegar is very
useful…I believe these things…my information is from these sources…” (Participant 9).
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Women navigated two healthcare systems when questions arose about treatments,
symptoms were not managed, or health alterations occurred suddenly when they were visiting
countries of origin. At times this leads to beneficial health outcomes where physicians
cooperated transnationally to the best interest of their patients or when treatments not available in
Canada were utilized successfully abroad. In describing successful treatment for managing a
chronic health condition a woman stated, “…I couldn’t find it in Lebanon and here they wouldn’t
give it to me so I ordered it from England….doctors here told me these injections are very very
good but we can’t order it for you because there isn’t any here so I brought it from England…”
(Participant 5).This woman’s family bought the medication, prescribed by a physician in
Lebanon, for her from Europe, to take in Canada. Other stories revealed that women were taken
advantage of for financial gain by healthcare professionals abroad wanting to benefit from their
perceived advantaged financial status as Canadians, “they tell me stop the Canadian medication
so I would buy medication there. I started to buy the medication…” (Participant 14).This woman
was later warned by a family member that the change was not needed but a way to get her to pay
more money.
Discussion
Stroke prevention involves managing chronic illnesses that increase stroke risk, making
healthy lifestyle adjustments, and accessing health-promoting resources. Women actively
navigated personal, social, and systemic barriers to engage in stroke prevention. These women
share many of the barriers and facilitators to health experienced by the general Canadian
population, but lack similar support mechanisms in the face of adversity. They, also, described
unique health influences centered on the experience of migration. Intersectionality is a process of
dissecting social structures and practices within different social spaces to draw attention to the
91
resulting influences on people’s lives (Anthias, 2009; Yuval- Davis, 2006). We discuss some of
the ways women’s social positioning served to limit or facilitate engagement in stroke
prevention. We then move to address some of the discourses and modes of representation that
can hinder progress towards better health outcomes for minority immigrant women ageing in the
Canadian context.
A Tug and Push Dynamic: Narratives of Exercising Personal Agency
Women’s narratives illuminate the role of personal agency in mediating, negotiating, and
re-structuring barriers to stroke prevention. Women were active in making decisions, weighing
options, and searching for opportunities to enhance personal health using both local and
transnational resources. Personal agency, however, is enacted within the constraints of one’s
social position (Anthias, 2009; Dhamoon & Hankivsky, 2011; Yuval- Davis, 2006). Women, in
telling stories about managing their health, were also telling stories of their social locations in
different social settings: their local communities, Canada, and country of origin. The tug and
push dynamics between personal agency and social structures result in shifting social positions
within different spatial and temporal locales for immigrant women (Chesla, Kwan, Chun, &
Stryker, 2014; Lane, Tribe, & Hui, 2011). Women leveraged their social positions in these
different settings to access supportive resources for health, such as seeking medical advice,
obtaining health remedies, and gaining encouragement to enhance well-being.
Deteriorations in physical health resulted in mental distress for some women amplifying
their positions of vulnerability as members of a linguistic and cultural minority group. During
periods of stressful transition, such as being diagnosed with a new disease or experiencing a
negative health event, women’s positions shifted to amplify the disadvantages of low education
92
and minimal economic resources. On the other hand, women’s positions as ageing adults in the
Canadian context resulted in access to social, financial, and healthcare resources within Canada’s
social safety net. Women were grateful as similar supports were lacking for ageing peers in
countries of origin. These women were socially positioned as advantaged in comparison to co-
ethnic peers in countries of origin. An effect of this was that women were at risk of being
targeted for financial gain when returning to countries of origin due to being perceived as well
off Canadians. Some women told stories of being given medical treatments or undergoing
procedures that were unnecessary. In conclusion, Arab immigrant women were not vulnerable all
the time in all contexts which points to categories of identity, such as immigration status and
ethnicity, as being erroneous indications of vulnerability.
Fallacies of Representation: Moving from Narrative to Discourse
Focusing on women’s capacity to negotiate positions that enhance power can result in
overlooking the structures that limit agency (Anthias, 2012). Canada has a public healthcare
system where stroke prevention, detection, and treatment are a priority at the health policy level
(Public Health Agency of Canada, 2009). Theoretically, immigrants are able to access this
system and utilize health-promoting resources. The literature points to Arab immigrants and
other ethnic minorities experiencing challenges in accessing and utilizing healthcare services
(Alzubaidi, Mc Narmara, Kilmartin, Kilmartin, & Marriott, 2015; Asanin, & Wilson, 2008;
Hasnain, Connell, Menon, & Tranmer, 2011; Lai & Surood, 2010; Padela, Gunter, Killawi, &
Heisler, 2012; Sanou et al., 2014;Vanstone, Giacomini, Smith, Brundisini, DeJean, & Winsor,
2013). All women in this study reported regular visits to family physicians and access to
specialist medical care. Frequent contact, however, did not always address knowledge deficits,
93
help manage disease symptoms, or support lifestyle adjustments for better health. Women
described experiences of poor diabetes and blood pressure control, unmanaged chronic pain,
emotional and mental distress, lack of knowledge regarding prescribed medication, and
unfamiliarity with signs and symptoms of stroke.
Global inequalities in health service distribution are reflected in local immigrant
communities, where immigrants bring to the host country experiences of healthcare interactions,
exposures to health risks or benefits, and approaches to personal health. In this study, the
healthcare realities of countries of origin remained influential in women’s lives, persisting after
spending decades in the Canada due to ongoing transnational ties. Engagement within a
transnational context can be interpreted as a positive reaction to negative experiences of
exclusion and othering (Portes, 1999; Salih, 2001). Transnational health utilization has been
documented in the literature for other immigrant populations, where the use of formal healthcare
services, procurement of medication and traditional treatments, and attainment of health
information occurs across borders in both countries of origin and destination (Horton, 2012;
Thomas, 2010; Wang & Kwak, 2015). Unmet local needs and the utilization of transnational
healthcare services points to immigrant women navigating a labyrinth of inequality to improve
the conditions of their lives. Re-presenting health inequalities to recognize marginalization
processes that place Arab immigrant women at the periphery of conversations about healthcare is
needed in Canada.
Conclusion: Limitations and Implications
This study is the first, to our knowledge, to look at Arab immigrant women’s experiences
with stroke prevention. The study findings reveal Arab immigrant women navigate health
94
resources locally and transnationally to increase access to health-supporting resources and
diversify options for health management. Women experience to varying degrees barriers to
exercising personal agency. Women who were more educated, had higher economic prosperity,
and were more fluent in English were more comfortable navigating the healthcare system and
utilizing health-promoting resources. Barriers were shaped by local and transnational processes,
pointing to the utility of intersectional approaches that look beyond national borders to
understand Arab immigrant women’s health experiences. The relationships among age, culture,
and gender and the resulting influences on shaping health experiences require further exploration
in the literature (Koehn, Neysmith, Kobayashi, & Khamisa, 2013). Shifting discourses on
immigrant health away from a focus on culture that stresses narratives of personal behaviors and
group cultural norms to a focus on the intersecting influences of multiple social positions will
better inform approaches to supporting healthy ageing in immigrant populations.
This was a small study targeting a group of Arab immigrant women in a single urban
center in Canada. Due to challenges with recruitment, we believe the most vulnerable and
isolated older women were not accessed. Community gatekeepers emphasized the increasing
presence of vulnerable older Arab women in the community and the lack of resources to address
their needs. The women interviewed and community gatekeepers put emphasis on the urgent
need for community-based initiatives that target the needs of older adults with chronic illnesses,
who are further isolated by low income, low levels of English fluency, and minimal social
support. Navigating health services was left to the women and their families, with family
members often attempting to fill in for health service gaps. Further efforts to increase research
recruitment and participation to address health issues are needed in this community.
95
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Chapter Five
Emphasizing Strengths and Identifying Challenges
I address in the dissertation two areas that relate to research with middle-aged and older
Arab immigrant women: my experience of the research process and women’s experiences of the
phenomenon of interest. I reflect on my role as a bicultural and bilingual researcher in ensuring
ethical and rigorous research processes (chapter two and appendix F). In the current political and
social climate discussions about Arab and Muslim populations take on various shades of othering
and difference. Chapter two shows that these conversations trickle down to impact the research
process in a local community and refocuses on strategies to increase collaboration and
understanding. One important consideration for enhancing understanding is working to critically
reflect and advance methods to ensure rigouros research processes with Arab and Muslim
populations (demonstrated through a work in progress in Appendix F). Working towards ethical
and rigorous research processes was aimed at creating safe spaces for women to voice their
experiences around health and ageing in the Canadian context. These experiences are
summarized below and can serve to inform nursing activites in research, practice, and education
that focus on supporting health in Arab immigrant populations.
The focus of women’s stories was on major areas of concern that created significant
stress in their lives, but these stories also revealed personal resourcefulness and resilience. Areas
of concern identified were transnational stressors that could result in neglect of personal health,
lack of social support to facilitate health management, a looming risk of loneliness and social
isolation, deficiencies in health literacy about stroke and stroke risk factors, and difficulties with
engaging in healthy lifestyle choices. Personal resourcefulness and resilience were demonstrated
in women’s use of local and transnational social networks to access healthcare resources,
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balancing of traditional remedies with Western medicine to enhance personal health, the reliance
on faith to cope with life stressors, and being a source of support for others. These findings are
discussed in chapters three and four. Chapter three addresses social dimensions of health with a
focus on transnational connections across the life course and availability of social support in the
post-migration context. Chapter four highlights the structural and representational influences on
health that stem from women’s social positioning locally and transnationally. Areas for concern
and identified strengths were contingent on women’s social positioning within their local
communites, Canadian society, and country of origin. Findings in this study at times mirror,
contradict, or expand available knowledge in the literature. I present in the following section
highlights of the findings that emphasize women’s strengths but simultaneously point to
continuing challenges with engaging in health-promoting practices in the context of stroke
prevention.
A new diagnosis of diabetes or hypertension or the occurrence of a stroke or cardiac
event was often understood by women as the result of stressful life events or the cumulative
effect of multiple life stressors. Asking women the question of ‘why do you think this happened
to you’ triggered telling of stories about personal life stressors. The connections between stress
and manifestation of illness have their roots in cultural and religious interpretations of the
holistic connection among body, mind, and spirit (Chaze, Thomson, George, & Guruge, 2015;
Shah, Ayash, Pharaon, Gany, 2008; Tirodkar et al., 2011). A closer look at women’s stories
shows that life stressors, whether ongoing chronic stressors or one-time stressful events, resulted
in negative perceptions of personal health. Women also reported neglecting personal health when
life stressors increased by stopping medication, not exercising, not eating well, and not following
up on health concerns. Loneliness was another concern experienced by many women in the study
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and opportunities to connect with others were emphasized as growing needs for older adults in
the community. Evidence continues to suggest associations of stress and loneliness with adverse
health outcomes in minority and non-minority populations (Aroian, Uddin, & Blbas, 2017;
Everson-Rose et al., 2014; Holt-Lunstand et al., 2015; Valtorta, Kanaan, Gilbody, Ronzi, &
Hanratty, 2016). The evidence also suggests that these associations cannot be explained solely by
the way stress and loneliness impact traditional risk factors such as lifestyle choices. This study
presents a subjective account of the ways stress, loneliness, and negative perceptions of health
manifest in the lives of Arab immigrant women.
Women reported not having adequate knowledge about their health conditions, stroke
risk factors, or health management strategies. They found it difficult to address modifiable stroke
risk factors such as physical activity, smoking, and diet; factors that account for high percentages
of risk across all ethnic and age groups (O’Donnell et al., 2016). Absence of culturally and
linguistically appropriate health literacy material and health management resources will likely
continue to be a serious area of concern for Arab immigrant women in light of the minimal
public health infrastructures in the Arab world (Jabbour, 2014). Arab women migrating to
Western countries will continue to face a double jeopardy. Armed with little knowledge or
previous exposure to health promotion about stroke prevention, they will then be exposed to an
array of new health stressors. This double jeopardy is not expected to be uniform across
subgroups of Arab immigrants but differs based on level of education, personal experiences with
health promotion, economic status, and acculturation level. For example, being able to drive and
having a stronger command of the English language enabled women to access and utilize more
community and healthcare resources that would benefit their health. Arab immigrants who are
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well educated and enjoy upon immigration some level of economic prosperity might have the
ability to effectively navigate the healthcare system and utilize resources for health promotion.
To summarize the above, the combination of decreased mobility, lack of social support,
low income, cultural and linguistic differences, and personal life stressors pushed some of the
women in the study into a downward spiral of vulnerability. Other women in the study were
resourceful in using local and transnational connections to navigate access to resources that
would help them effectively manage their health. Many of the challenges women experienced
mirror those of the wider ageing Canadian population living with chronic illnesses and reflect a
gap in community services that support healthy ageing (Public Health Agency of Canada, 2010).
Other challenges were more specific to immigrant minority groups that have cultural and
linguistic differences from the dominant society. Two barriers to health, being at the receiving
end of discrimination and experiencing role conflict, identified in the literature on immigrant
women did not surface as primary concerns in women’s stories in this study. One out of four
Arab Canadians reports experiencing discrimination based on race or religion (Statistics Canada,
2007). Experiences of discrimination are shown to differ based on religion, social class,
acculturation levels, and country of origin (Abdulrahim, James, Yamout, & Baker, 2012; Derose,
2009). Women when asked explicitly and throughout the interviews often denied experiences of
discrimination in relation to healthcare access and utilization. They did describe efforts to
connect with non-Muslim neighbors and represent Arab Muslims positively to combat
misconceptions. Women might have wanted to emphasize the positive aspects of the healthcare
system as the interviewer was known to be a registered nurse. It might also be that women truly
did not feel that discrimination was part of their experiences in utilizing and gaining access to the
healthcare system.
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The second area often addressed in the literature on immigrant women relates to
changing social roles and role conflict with increasing age. Some studies emphasize ageing
immigrant women’s experiences of liberation from traditional gender roles (Charpentier &
Quéniart, 2016; Chun, Chelsa, & Kwan, 2011), while other studies highlight the continuation of
traditional caregiving roles for spouses, children, and grandchildren (Grewel, Bottorff, & Hilton,
2005; Lai & Surood, 2008). In this study women seemed to carry on the traditional gender roles
of being homemakers and caregivers with pride and a sense of self-worth. These roles did not
appear to be sources of conflict in their lives. Women acknowledged, however, that these roles
became sources of stress and resulted in neglect of personal health during periods of disruption
involving family strife, increase in familial obligations, or personal illnesses. Overall, study
findings point to the need for approaching health management in Arab immigrant women from a
holistic perspective addressing the contextual factors that can facilitate or limit their ability to
engage in health-promoting practices across the life course.
Towards a Life Course Interpretive Framework: Guiding Concepts
This study involved simultaneous immersion in the data and reflection on the wider
processes and structures that shaped women’s experiences around stroke prevention. In early
phases of data analysis, I sensed that women were saying something different; women were
contradicting my prior conceptualizations of temporality and spatiality in the life course
paradigm. This process allowed for the use and refinement of three guiding concepts that shape a
life course interpretive framework focused on immigrant women, health, and ageing.
Three contexts are central in conceptualizing immigrant health from a life course
perspective: (a) pre-migration, (b) migration, and (c) post-migration. Migration contexts
refer to the politically, historically, and socio-economically contingent realities of the
106
countries of origin and destination as experienced by immigrants. Understanding life
course influences on immigrant health necessitates considering migrants’ pre-migration
positioning and the resulting effects on migration and post-migration contexts
(Abdulrahim, & Ajrouch, 2014; Castan˜ eda et al., 2014). Pre-migration contexts are
always changing, where different cohorts of immigrants from the same country might
have lived within very different socio-economic, environmental, and political contexts.
The majority of women in this study had lived in Canada for decades and this meant the
post-migration context was the most significant direct influence on health. The pre-
migration context might be more relevant for new immigrants and the migration
experience more relevant where trauma and disruption during the migration process are
substantial.
Immigration constitutes a major life transition and this transition impacts health through
creating pathways of exposure to stressors or exposures to facilitators of health (Messias,
2010). Health stressors constitute factors that directly or indirectly result in negative
health outcomes, while health facilitators constitute factors that directly or indirectly
result in positive health outcomes or prevent negative outcomes. Women were telling
stories of a spiral process involving moving back and forth across migration contexts
within transnational spaces. This process of moving back and forth was at times physical,
such as traveling to country of origin to be caregivers or seek healthcare services. This
process could also be emotional, where social, economic, and political disruptions in the
country of origin resulted in ongoing perceptions of a stressful life. It has long been
documented that Arab women continue transnational connections in the post-migration
107
context (Meleis, 1991; Naber, 2009). Yet, I found minimal incorporation of this concept
in research that lies at the intersection of immigration, ageing, and health.
A constructivist approach to life course theorization attends to the meanings ascribed to
life course experiences and searches for subjective interpretations of time, place, and
events (Holstein & Gubrium, 2007). Subjective interpretations are situated within
temporal and spatial realities of immigrant’s lives to create an understanding of
contextual truths. These temporal and spatial realities shape and are shaped intersections
of social locations women occupy, which requires attention to the workings of power.
Women migrate under different circumstances than men and embody different pre-
migration and post-migration realities. Women’s health experiences and outcomes are
influenced by the intersecting and counter-influencing spheres of social belonging across
gender, ethnicity, and class (Anthias, 2009; Hankivsky & Christoffersen, 2008; Yuval-
Davis, 2006).
Implications for Future Practice, Policy, and Research
Practice Considerations
Concerns raised by women in this study can be useful to nurses engaged in health
promotion activities around chronic disease management. Women unanimously discussed the
risk for social isolation and loneliness, even when living in an Arab dense neighborhood and
having family actively involved in their lives (addressed in paper 2). A second issue raised by
women was the lack of access to health promotion resources and services in the Arabic language
(addressed in paper 3). Nurses who work with Arab immigrant women should also consider the
influences of transnational stressors on health and the potential access to transnational health-
promoting resources. For example, when Arab immigrant women discuss travel plans or nurses
108
sense dissatisfaction with available treatment options in Canada, it is worth asking about goals of
accessing transnational healthcare services and resources. The aim would be to provide
information and foster collaboration when possible to ensure a cohesive and holistic approach to
women’s health. Another study finding that nurses might benefit from understanding is the
central role of food in the lives of Arab immigrant women. Cooking, sharing food and hosting
gatherings, and cultivating pride in personal culinary skills were essential components of
women’s lives. Nurses often take on the role of teaching about lifestyle modifications, such as
dietary changes. Recognizing that food might not simply be a source of sensual pleasure but a
source of identity, connection to the past, and a means for memory making ensures sensitivity to
the impact, for example, of asking someone with diabetes to change their cooking habits and
dietary intake.
Policy Considerations
Immigrant visible minority women, even when highly educated, are more likely to be
unemployed or underemployed in comparison to other Canadian women and immigrant men
(Tastsoglou & Preston, 2005), which decreases opportunities for integration, economic security
and language attainment. Such experiences are likely to influence women’s abilities to manage
health effectively as they age in the Canadian context. In a study of younger Arab immigrant
women who were not in the workforce, had low levels of education, lacked social support from
family and friends, and had poor language skills, there were reports of high levels of emotional
distress and loneliness (Irfaeya, Maxwell, & Krämer, 2008). In our study, these findings were
mirrored in middle-aged and older women with similar socio-demographic characteristics, which
point to pathways of vulnerability that begin early on and progress as women age in the post-
migration context. Barriers such as lack of language skills could be addressed in early phases of
109
resettlement in the post-migration context by providing language services to increase integration.
At the policy level, funding also needs to address the practical needs of women in their daily
lives that influence the ability to learn and work, such as affordable childcare and transportation.
Canada is also accepting high numbers of refugees from Muslim and Arab countries. This
population might need enhanced support for social and economic integration due to similar
barriers experienced by women in this study in the early migration phase. Refugee populations
experience additional stressors related to witnessing violence, forced displacement, death of
loved ones, and family left behind (Freund, 2015). These factors disrupt the social dimensions of
health discussed in this study as influential in women’s abilities to engage in health-promoting
practices. There continues to be a need for policy approaches and funding to focus on the long
term health of refugees in the context of non-communicable diseases, such as cardiovascular
health (Patil, Maripuu, Hadley, & Sellen, 2015; Yun, Graber, Sullivan, Chen, & Gup, 2012).
This study points to some of the processes and structures that require attention to successfully
promote health in populations from Arab contexts.
Research Considerations
For the researcher who wants to engage in research with Arab immigrant women the first
paper and appendix F point to important ethical and methodological considerations. Some main
considerations for researchers embarking on research projects with Arab Muslim immigrant
communities are the need to engage in self-reflexive processes, to ensure reciprocity, and to
address translation and conceptual clarity issues. Engaging in a reflexive process requires
researchers to understand their position in relation to the community of interest, be aware of
personal biases, and recognize prevailing discourses and socio-historical narratives of a
particular community. Reciprocity refers to the need to give back to the community in a way best
110
identified by that community; for this project giving back involved volunteering in a non-
essential positon to help start a seniors’ social and exercise group and providing community
leaders with a summary of research findings. Potential problems with translation and conceptual
clarity necessitate that researchers make explicit the processes used to ensure authenticity and
trustworthiness of research findings. We found the resources sparse in the English language
literature addressing these issues and encourage future bilingual researchers to make their
processes explicit. It would be useful for a researcher, especially when a novice, to have a second
researcher familiar with the language and culture to support the research process. Other
pragmatic considerations were that face to face introductions to potential participants were
essential for building trust, with snowballing methods not as effective as cited in the literature
(see chapter 2). Another practical consideration is the timing of year when recruitment is most
effective. Summer months were not a good time to recruit participants since this was when
women traveled back to the Middle East or were busy visiting with children and family coming
from other provinces or from abroad. Winter months were the most effective recruitment time;
maybe because there was more free time for women to schedule interviews and the weather
limited possibilities for leaving home.
Study Limitation and Strengths
This study was conducted in a small Arab community in a major urban center. Contact
with the community began in June of 2015 and the first participant was recruited in September of
2015. Between September 2015 and May 2016 a total of 16 women were recruited for the study.
Time constraints meant termination of the study occurred while interest in the study was ongoing
and potential participants were still coming forward. This study has increased the community’s
familiarity and comfort with participating in future research. The study also provided valuable
111
lessons regarding effective strategies for recruiting Arab communities to participate in research
projects. The women in this study varied in terms of degrees of vulnerability, where some
women were able to navigate barriers, draw from personal resources to maximize health, and
express a sense of satisfaction with their lives. Other women were unable to overcome barriers in
significant ways that would allow them to manage health in an effective manner. Community
gatekeepers related that the most vulnerable women were hard to reach and would be difficult to
recruit. This necessitates looking for ways to increase recruitment of Arab and Muslim
vulnerable older adults. With the increase in negative political discourses around Muslim and
Arab populations, engaging these communities in research to address health needs might
continue to be a challenge. Participants in this study were Arab Muslim women from the Levant
region. Claims for transferability of findings to other communities of Arab women who are not
from the Levant region or to Arab women from other faith groups cannot be made. Women in
this study cite marriage as a primary reason for migration, with pursuit of a better life, escape
from political instability and violence, and desire to be with family already in Canada also
influencing the decision. The study population was not highly educated or involved in the
workforce (except for one of the women). Their experiences of migration probably do not mirror
those of more educated or more recent economic migrants where social mobility and educational
advancement can be driving factors (Killian, Olmsted, & Doyle, 2012).
This study emphasizes the multi-dimensional and inter-weaving systems and processes
beyond culture and religion that shape vulnerability and impact health. The attempt to make
these systems and processes identifiable and transparent allows for better use of research
findings from a small study; consumers of this research project can decide for themselves
whether the suggestions are relevant to their particular context. I emphasize the need for
112
building on this study to determine transferability of findings to other groups of Arab immigrant
women. I also recognize that this study does not capture all that could be said about Arab
women’s experiences with stroke prevention.
Areas for Future Research
The objective of the study was to identify factors across the life course that facilitate or
limit middle-aged and older Arab immigrant women’s abilities to engage in stroke prevention
practices and to identify gaps in resources that influence supporting women in managing stroke
risk. The need to address health disparities by managing chronic health conditions and
improving quality of life necessitates attending to the structural, social, and environmental
contexts of people’s lives (Quiñones, Talavera, Castañeda, & Saha, 2015; Rogers et al., 2015).
This study was a first step towards addressing a broader research objective of identifying
strategies to enhance stroke prevention practices in Arab immigrant populations across genders.
There is evidence that Arab men continue to experience challenges with managing stroke risk
factors ((Phillips, Monaem, & Newman, 2015; Tailakh et al., 2013; Tenkorang, 2017). I focused
on women’s health, but frequently during the study spouses and family members would
comment on personal health struggles and perspectives on access to healthcare resources. Their
stories were excluded from the final analysis because ethical approval had not been obtained to
incorporate family perspectives. From the literature on continued barriers to health experienced
by immigrant Arab men and from the interest expressed by spouses of women in this study,
further attention is needed in research to experiences and support needs within Arab families
across genders. The more collectivist nature of Arab families might mean that research
approaches that incorporate families will see more success in recruitment.
113
Another area for future research is looking at the influence of transnational ties on
immigrant health. For example, researchers could look at the experiences of healthcare
professionals supporting immigrants in navigating transnational healthcare resources. Women
shared stories of collaboration between physicians in Canada and country of origin with positive
health outcomes. One woman's sister was diagnosed with a genetically linked form of breast
cancer in the Palestinian territories and was told by her physician to inform siblings in Canada.
The woman shared this information with her physician resulting in enhanced screening and
identification of early breast cancer. A second woman spoke of consulting a specialist in country
of origin for assistance with a prolonged gynecological problem and having her Canadian
physician implement the specialist's recommendations. Delving into the experiences of
healthcare professionals and their patients with accessing transnational healthcare resources was
beyond the scope of this study, but constitutes an interesting area for future research.
Another area for future research relates to the way Arab immigrant women understand
and participate in exercise in the presence of barriers such as chronic pain and physical
limitations. Many women in the study recognized the need to engage in physical activity to
decrease stroke risk, but lacked knowledge on effective strategies and exercise techniques. At
the time of the study, weekly exercise sessions were being held at one of the recruitment
locations. Older women took part in chair exercises by following an exercise video played on a
projector screen. The women also participated in indoor group walking sessions. Informal
discussions with women revealed satisfaction from these activities and an increase in exercise at
home using techniques modelled in the video. The weekly exercise activity was spontaneously
initiated based on women's requests, but opened my eyes to possibilities for initiatives that take a
holistic approach to engaging women in health-promoting activities. The exercise activity
114
allowed for simultaneous attention to physical health, social connection, and spiritual
development as activities were followed by prayers or short religious sermons. It would be useful
to build on these findings and the literature (Barenfeld, Gustafsson, Wallin, & Dahlin-Ivanoff,
2015; Campbell et al., 2007; McCaffrey, 2008) that supports a multi-focus approach to health
promotion initiatives targeting physical, spiritual, and mental health of immigrants. Further
research is needed on what works to increase Arab immigrant women’s quality of life and
empower women with tools to effectively manage their health. These research approaches can
expand to incorporate looking at cardiovascular conditions that share similar risk profiles with
stroke.
Study Dissemination Process
There is little research on stroke prevention in Arab immigrant women. This study is, to
my knowledge, the only study that looks specifically at stroke prevention in Arab immigrant
women. Understanding stroke risk, prevention, and management is increasingly relevant as the
number of immigrants from the Arab world continues to increase. Also, this study adds to
available literature that highlight gaps in resources and call for increased attention to chronic
disease management in Arab populations (Alzubaidi, Mc Namara, Browning, 2017; Hammad,
Said, & Arfken; 2014; Levin-Zamir et al., 2015). Dissemination of the findings from this
research project is ongoing and includes presentations at conferences and publications. Initial
findings were presented at a national and a local conference. The first paper has been published
in Advances in Nursing Science and hopefully will stimulate conversations around ethical
research practices with Muslim Arab women. The goal is to submit the findings papers (chapter
3 and 4) and the methods paper (appendix F) for publication in peer-reviewed nursing journals.
115
Dissemination also included taking a summary of the findings to the community leaders
who facilitated recruitment and are actively involved in addressing the needs of seniors in their
community. The participating community identified knowledge deficits regarding managing
chronic conditions such as diabetes and cardiovascular disease concerns. A second area
highlighted was the need for more social and recreational activities for seniors in the community
who have cultural and language barriers that limit access to wider community resources offered
to seniors. In follow-up to this study, further conversations with the community will occur to
identify possible strategies to address knowledge deficits and social isolation in community
seniors. It is hoped that the findings of this study will support the community’s activities to
increase access to and development of initiatives that target the needs of seniors.
Final Thoughts
One of my favorite memories is of an older woman who asked me to look out the
window of the living room where we were sitting drinking tea. She pointed to a car parked out
front, and said something to the effect of: ‘I don’t use it a lot but I like to look at it parked out
there, ready for when I need it.’ This memory stood in stark contrast to my memory of another
older woman in the study. She also pointed outside her window while we were drinking tea. She
pointed to a house across the street. A good friend lived there but it had been weeks without a
visit. Mobility difficulties prevented her from walking across the road to her friend's home.
Experiences like this heightened my awareness of the complexity of variables that influence
immigrant women's experiences of aging in Canada. Arab immigrant women in this study share
many of the strengths and challenges of their Canadian counterparts ageing in our Canadian
urban centers. These women also experience unique strengths and challenges stemming from
cultural and religious beliefs, transnational connections, and immigration experiences. I was
116
simultaneously inspired by their strength and pained by the difficulties narrated in their stories.
This research project has been an intellectual and emotional journey with the outcome of better
awareness of myself, the participating community, and the chosen research topic. This awareness
involves recognition of the many questions that still need answers. In gaining consent for this
study, women asked that I bring their voices forward with authenticity and truthfulness. This
dissertation project reflects my attempt to meet their expectations and present my account of the
journey.
117
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Appendix A: Recruitment Posters
Have you had a stroke or a transient ischemic
attack?
We would like you to participate in a study. We want to understand the
needs of the Arab immigrant community in caring for their health in the
Canadian context.
If you are:
an Arab Immigrant to Canada,
45 years of age or older, and
you have previously had a stroke, we would like your input.
If you are interested in this study, please contact Jordana Salma
(Registered Nurse, Doctoral Student at the University of Alberta):
Phone: (780) 263-8438 Email: sjordana@ualberta.ca
158
Appendix B: Sociodemographic Questionnaire
1. Age:
2. Country of origin:
3. Nationality (please indicate if you have more than one):
4. Ethnicity:
5. Education:
6. Occupation:
7. Yearly personal income:
8. Yearly family/household income:
9. Year of immigration to Canada:
10. Number of years in Canada:
11. Year of stroke event(s):
12. Physical/cognitive deficits, if any, resulting from stroke:
13. Chronic illnesses/health problems:
14. Medication:
15. Alcohol/smoking consumption:
16. Weight: Height: (self-reported)
159
17. Access to family physician:
18. Last physician visit: total visits/year:
19. Use of other health services:
20. Frequency and type of physical activity:
21. Frequency and type of leisure activities:
22.
Date of completion: ----------------------- Initials of Participant: -----------------------
160
Appendix C: Interview Guide
Opening Questions:
Describe your current health
What do you think caused your stroke (or disease risk factor)? Do you think you
could have prevented it?
Describe the ways you currently maintain your health
What are you doing to prevent another stroke (manage your risk factors)?
Describe the factors that make taking care of your health easier? More difficult?
What guidance were you given about preventing another stroke? Was that
information helpful?
Probes:
Personal definition of health
Current mental and physical health problems
Comparison of current health to past health
Stroke severity, timing, symptoms, post-stroke deficits, interaction with healthcare
system
Knowledge and access to secondary prevention resources
Knowledge/practices/challenges with diet, medication adherence, physical
activity, smoking, weight, health monitoring
161
Tell me about your social life in Canada.
Probes: living arrangements, relationship with family in Canada/country of origin, social
activities, availability and type of social support for health maintenance.
Tell me about your journey to immigrate and settle in Canada.
Probes: pre-migration conditions, reason for migration, positive and negative aspects of
immigrating, impact of immigration on health.
Describe the factors you think can support or hinder engaging in stroke prevention
practices.
Probes: healthcare system factors, social factors, gender, culture, environmental, personal
factors, genetics.
162
Appendix D: Information Letter and Consent Form
Information Letter
Title of research study: Stroke Prevention: Facilitators and Barriers in Middle-Aged and Older Adult Arab
Immigrant Women.
Investigator: Jordana Salma, RN, PhD candidate Phone Number: (780) 263-8438
Supervisor: Linda Ogilvie, RN, PhD Phone Number: (780) 430-9221
Purpose: You are being asked to participate in a research study. The study will look at the facilitators and
barriers Middle-aged and Older Adult Arab Immigrants experience in caring for their health after
experiencing a stroke event or when living with stroke risk factors.
Procedures: If you agree to participate in this study, Jordana Salma will meet with you for an interview. The
interview will take 1 to 2 hours. Jordana will ask you questions about your health and your health care
practices. The questions will relate to your experience of having a stroke, the factors that facilitate or hinder
your ability to maintain your health, and your health care experiences in Canada. Jordana will choose an
interview location comfortable for you. The interviews can be done in Arabic or English. The interviews
will be audiotaped.
Possible benefits: There are no direct benefits to taking part in this study. This study will help health care
professionals understand the experiences of Arab immigrants who have had a stroke.
Possible risks: You might feel uncomfortable by some of the questions. These questions are about the
difficulties you experience with your health. Otherwise, there are no known risks for taking part in this
study.
Privacy: We will keep the information you provide strictly private. Jordana will use numbers to name you on
the interview records. Any information made public will not identify you by name. Jordana Salma will lock
the interview records in a safe place and destroy them after seven years.
Additional contacts: If you have any additional questions about this study feel free to contact Jordana Salma
using the contact number provided above or email: sjordana@ualberta.ca. If you have any questions about
your rights as a research participant or about the ethics of this study you can contact the Health Research
Ethics Office: 308 Campus Tower, 8625-112street, Edmonton, AB, T6G 1K8
reoffice@ualberta.ca
Phone: (780) 492-0459 Fax: (780) 492-7808
Voluntary Participation: You are free to withdraw from the research study at any time. You can withdraw
before or during the interview process. You do not need to give any reasons for leaving the study.
Payment of Expenses: There will be no rewards for participating in this study. We will provide you with
travel costs.
Signature of Research Participant: _________________
Printed Name: _________________________________Date: ___________
Signature of Investigator: ________________________ Date: __________
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Consent Form
Title of the research study: Stroke prevention: Facilitators and Barriers in Middle-Aged and Older Arab
Immigrant Women.
Investigator: Jordana Salma, RN, PhD candidate Phone Number: (780) 263-8438
Supervisor: Linda Ogilvie, RN, PhD Phone Number: (780) 430-9221
_____________________________________________________________________
Do you understand that you have been asked to be in a research study?
Have you read and received a copy of the attached Information Sheet?
Do you understand the benefits and risks involved in taking part in this research study?
Have you had an opportunity to ask questions and discuss this study?
Do you understand that you are free to withdraw from the study at any time, without having to give a
reason and without affecting your employment?
Has the issue of confidentiality been explained to you?
Who explained this study to you? _____________________________________________________
I agree to take part in this study: YES NO
Signature of Research Participant: _________________
Printed Name: _________________________________
Date: ______________________________
I believe that the person signing this form understands what is involved in the study and voluntarily agrees to
participate.
Signature of Investigator: ________________________________ Date: __________
THE INFORMATION SHEET WILL BE ATTACHED TO THIS CONSENT FORM AND A COPY
GIVEN TO THE RESEARCH PARTICIPANT
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Appendix E: Confidentiality Agreement
Title of Study: Stroke Prevention: Facilitators and Barriers in Middle-Aged and Older Adult
Arab Immigrant Women.
I, , the (specific job
description, e.g., interpreter/translator) have been hired to
I agree to -
1. keep all the research information shared with me confidential by not discussing or
sharing the research information in any form or format (e.g., disks, tapes, transcripts)
with anyone other than the Researcher(s).
2. keep all research information in any form or format (e.g., disks, tapes, transcripts) secure
while it is in my possession.
3. return all research information in any form or format (e.g., disks, tapes, transcripts) to the
Researcher(s) when I have completed the research tasks.
4. after consulting with the Researcher(s), erase or destroy all research information in any
form or format regarding this research project that is not returnable to the Researcher(s)
(e.g., information stored on computer hard drive).
5. other (specify).
(Print Name) (Signature) (Date)
Researcher(s)
(Print Name) (Signature) (Date)
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Appendix F: Ensuring Rigor in the Research Process
Nurse researchers continue to engage in research activities with ethically and
linguistically diverse populations in the Western context to identify and address health inequities.
This has drawn attention to the need for ethically driven and methodologically sound tools to
ensure rigorous research processes and outcomes across linguistic and cultural mediums
(MacKenzie, 2015; Ogilvie, Burgess-Pinto, & Caufield, 2008; O’Conner, 2004; Meleis, 1996).
Interpretive Description [ID] is a methodological approach to qualitative research that is gaining
momentum because of its pragmatic orientation towards enhancing disciplinary knowledge in
nursing (Thorne, 2016). I used an interpretive descriptive approach to study the health
experiences of Arab immigrant women. There has been an increase in the use of qualitative
methods with Arab populations that brings attention to linguistic and cultural considerations for
ensuring rigor (Ahammed, 2015; Al-Amer, Ramjan, Glew, Darwish, & Salamonson, 2016;
Hawamdeh & Raigangar, 2014; Thomas, 2008). I draw from my experience as a novice doctoral
researcher and from the broader literature on cross-cultural research practices to highlight
considerations for data collection and analysis.
I positioned myself from the onset of the study as a bilingual bicultural researcher
conducting the majority of data collection and analysis in the Arabic language. All languages are
embedded within a cultural and historical conceptual universe; the use of a particular language in
research influences the meaning making processes. In cross-language contexts the researcher
must explicitly state the techniques and methods used to collect, analyze, and record data, such
as translation processes, techniques to ensure conceptual equivalency, and rationale for language
choices (Squires, 2009; Temple, Edwards, & Alexander, 2006). The Arabic language can be
described as high-context versus English which is seen as low-context (Zaharna, 1995). High-
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context languages emphasize meaning making through the communicative process, where the
burden of understanding falls on the listener who uses physical and emotional cues to grasp the
underlying message. Low-context languages are more explicit and analytical with the
expectation that the speaker convey a message in a way that is understandable to the listener.
Differences in the function and expectations around language impact qualitative research
processes that depend on interviews as a primary data source. The first focus of this paper is to
elaborate on the meaning making processes that shaped data collection and analysis in the Arabic
language. The second focus is to describe the challenges of learning the craft of qualitative
research as a novice balancing considerations for methodological rigor. In the following sections,
I outline the study, give a brief introduction to ID, and present considerations for data collection
and analysis.
Study Question and Process
The research objective was to understand experiences around stroke prevention in a
group of Arab immigrant women ageing in Canada. Approval was obtained from the University
Ethics Board before commencement of the study. I recruited 16 women who emigrated from the
Levant region of the Middle East and were currently living in a large Canadian urban center.
Recruitment and data collection for this study occurred between June 2015 and May 2016.
Women were recruited from a mosque and an Islamic community center. I conducted semi-
structured interviews and administered socio-demographic and health questionnaires in the
Arabic language. Interviews occurred mostly in participants’ homes and lasted between 2 to 4
hours. I completed transcription and data analysis in Arabic, with final translation of themes and
exemplars into English. The focus of this paper is on the data collection and analysis process;
this involves considerations for the interview process, transcription and analysis of data, and
167
development of final themes. I outline my struggles and successes with enhancing rigor in using
an ID approach to study the experiences of Arab immigrant women. In the following section, I
present an overview of the ID methodology and outline relevant implications for data collection
and analysis.
Interpretive Description
Interpretive description is a method used to investigate a clinical phenomenon important
to nursing, by extracting themes that are based on subjective interpretations of experiences, with
the goal of generating findings useful to nursing practice (Thorne, Kirkham, & O’Flynn-Magee,
2004). Interpretive description focuses on knowledge development using a combination of data
collected in the practice field, prior knowledge in the area, and abstract theorization (Thorne,
2016). The philosophical underpinnings of an ID methodology are that reality involves
multiplicities that are subjectively and socially constructed, human commonalities and variations
exist in every aspect of human experience, and the researcher is inseparable from the object of
research. In approaching this research study, I was conscious of my shifting social position in
relation to the research community as both an insider, based on my Arab and Islamic heritage,
and an outsider, based on my status as a researcher and healthcare professional. I was aware that
these multiple social locations shaped my approaches to engaging in research. I was also aware
that despite identifying Arab women as a focus of study, women participating in the research
process embodied multiple social locations which influenced the interview encounters and the
narratives that emerged from these encounters. The fit between question and methodology
seemed initially unproblematic. I discovered, however, in the process of data collection and
analysis these varied social locations brought attention to cultural and linguistic nuances that
added a dimension of complexity to the research process. I also experienced challenges related to
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being a novice researcher learning the craft of qualitative research. I describe below my
experience and considerations for future research in the areas of interviewing, transcription and
translation, and data analysis.
Considerations for Data Collection and Analysis
The Interview: Encouraging the Narrative Process
Eliciting the senses. The interview guide initially used semi-structured questions that were too
rigid to elicit rich responses from women in the study. For example, such questions were
responded to with short answers or met with silence. Some women would ask: ‘what would you
like me to answer?’ Eliciting storytelling was more effective for engaging older Arab women;
the dynamic switched to that of an elder transmitting knowledge, experiences, and life lessons to
a member of the younger generation. Meaning making develops through reflection on behaviors,
feelings, and thoughts to create a story of oneself in the world and can be facilitated through use
of body awareness and sensory stimuli in the research process (Sharma, Reimer-Kirkham, &
Cochrane, 2009; Stetler, 2010). To help women turn inward and reflect, I elicited the senses as a
departure point in our discussions about health. Visual and tactile stimuli, like showing the
interviewer pill bottles and medication, served to start a conversation about perceptions of health:
Interviewer: Can you show me your medication (pause to look at medication) When you
look at this medication what thoughts do you have?
Participant: I don’t like to think about it.
Interviewer: Why is that?
Participant: Because in my entire life I never took medication. I started in the last two
years. Moving forward what is going to happen? My husband does not know the
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medication I am on. I mean what if I die. He doesn’t know anything about me. I came
from [city in other province] not on any medication. I might have taken Aspirin and
Tylenol. I would take these pills and they would put me to sleep because my body was
not used to medication.
Interviewer: You said you are worried about what could happen, you are worried about
the future?
Participant: Yes.
Interviewer: In what way?
Participants: That my health will get worse. (Participant 4)
Hawamdeh & Raigangar (2014), in one of the few discussions in the literature on
interviewing Arab populations, describe participants’ struggles to narrate, where they questioned
the worth of their narratives or focused on giving perceived correct answers. The interviews in
Hawamdeh & Raigagner’s study occurred in an institutional setting with employee nurses which
might have contributed to interview anxiety. I identified, however, a similar pattern with the
women in this study where women needed encouragement in telling their stories and frequent
assertions that their narratives were valuable to the researcher.
Managing intense emotions. Strong emotions of sadness, anger, and worry emerged in the
interview process. This did not relate necessarily to women being vulnerable or in crisis, rather
the women perceived the interview as an opportunity to share the stressors in their lives with a
sympathetic listener, without losing face as might occur when these stressors are discussed
within their social networks. In re-reading the first few manuscripts it was evident that I was
uncomfortable with these experiences of intense emotions; I would change the topic or jump into
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a consoling mode. This resulted in loss of opportunity for further insights or superficial
understandings of the sources of these strong emotions:
Participant: …I am scared, he has not been feeling well and I am worried about him…he
has many health problems, he has diabetes and he takes medication for his heart, and
cholesterol, and his thyroid and he has an appointment tomorrow with a specialist. Now
he has dizziness and tremors (starts to cry)….they told him this is the beginning of it and
referred him to a specialist.
Interviewer: Beginning of what?
Participant: I don’t know what they call it. We still don’t know. We will see the physician
tomorrow (continues crying).
Interviewer: You are bothered by this…
Participant: All we have is God in this country
Interviewer: You feel that all you have is each other?
Participant: That’s it (seconds of silence)
Interviewer: Tell me about other ways that you care for your health? (participant16)
As the study progressed, the use of silence and the reference to food were the most
effective strategies in dealing with strong emotions, allowing for opening up to discuss difficult
topics. Food was the soul of this research project; sharing food, swapping recipes, and boasting
about culinary skills created safe spaces and normalized the interview encounter. With strong
emotions in an interview and when second interviews are not scheduled, knowing when to end
the interview was important to avoid unresolved feelings or experiences left untold. Probing into
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painful memories was avoided when unrelated to the research question. I always asked myself:
‘is going there necessary for the data?’ This question ensured that curiosity did not lead to asking
unnecessary questions that women might later regret answering or that would force reliving
painful memories. Wegraf (2001) advises letting the participant guide us to when the interview is
over by watching for statements that indicate comfort with terminating the interview. The
interviews ended when women made statement such as: ‘I told you everything I have to say.’ or
‘You know my life story now.’ Women were asked if mental health support was needed and
were offered information on resources on two occasions when I sensed possible emotional
distress or mental health issues.
Embracing multiple agendas and expectations. At various points in the interview process it
was apparent that the agenda of the interviewer and that of the interviewee were at odds.
Increasing the understanding of stroke prevention in immigrant women meant engaging in a
process of always returning to the question. Socialising, giving advice, and venting emotions to a
sympathetic ear were alternate agendas that were brought by participants to the interview
context. These interactions were valued as authentic expressions of self-identify and personal
beliefs shared with the interviewer whose insider status allowed for relating to participants’
experiences:
Interviewer: Are there needs that you have that are not met here?
Participant: Like food for the house?
Interviewer: Could be anything in your life, not only food.
Participant: To tell you the truth I have a lot of needs not met. Am I in need of this
isolation? I am not happy and being away from home I find it very hard. When I feel
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overwhelmed from thinking I open the window and take a deep breath. To tell you I am
happy, no, I am not happy. This country has a lot of good and it is safe and there is
honesty and it has everything you could want, like living in heaven. When I think I left
my country and my family, being away becomes difficult…..do you have girls or boys?
Interviewer: One girl and two boys.
Participant: God keep them protected for you. Listen, stay in this country and work hard
and create a future for yourself and your children…then return to your country. It is
enough they do not hear the Athan [Muslim call for prayer from mosque minarets] here
and if they enter a mosque they do not understand what the imam is saying. You are at
work and their father is at work…school starts at home with the mother… [Continues
with detailed description of how she raised her children in Syria as a single mother,
working as a housekeeper, and the respect she received in her community] (Participant
10)
Reminiscing about her social life in Lebanon, the support she had in her community, and
the wide network of friends, created the opportunity for further questions about her social
networks and support in Canada. Koven (2014) describes the interview as an ‘ideologically
mediated speech event’, which requires that the researcher understand and accommodate the
communicative norms in the interview process to ensure comfort of both parties. I was familiar
with the expectations of communication with Arab elders that centered on respect, listening to
stories, receiving advice, and avoiding being perceived as too intrusive.
Some women in the study expected a rigid ‘I ask- you answer’ type of interaction
because using the word research and interview conveyed the idea of a serious, institutional,
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constrained communicative event. It often took the first half hour of the interview to re-set
mutual expectations on the interview style, which always yielded more in-depth and reflective
narrations. The use of humor, analogies, and metaphors is part of Arab language communication
(Zaharna, 1995) and conveyed important messages about women’s experiences with stroke
prevention. Comprehending these messages required an understanding of the Arab culture, life in
the Levant region, and Islamic norms. Comprehending these messages also required situating
culture, past experiences, and religious norms within the specific context of women’s lives at the
times of the interviews. It could be argued that if qualitative researchers are expected to engage
in an interpretive process, then qualitative researchers working in the Arabic language cannot
avoid engaging in this interpretive process; high level interpretation being a function of
interpersonal communication in the Arabic language. In the interview context, I found that more
open-ended forms of questioning that elicited the senses, followed by more structured questions,
was a successful strategy to gain in-depth and reflective responses. This form of interviewing can
be useful within all qualitative interview contexts and requires practice for novice interviewers.
Using multiple interview encounters might allow for increased participant comfort and more
time for reflection in Arab older adult populations.
Transcription and Translation: Accommodating Linguistic and Cultural Nuances
Moving between spoken dialects and written Arabic. Arabic has both a spoken form,
colloquial Arabic, and a written form, Modern Standard Arabic [MSA] (Haeri, 2000). Colloquial
Arabic is spoken in multiple dialects that differ by country and region. Levantine Arabic relates
to the Arabic spoken in the Levant region but still includes variations across urban and rural
contexts and across national borders in the region. Modern Standard Arabic is taught in schools
across the Arab world and is used mostly in formal conversations amongst the educated class.
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Rigor in qualitative interviews includes attention to accuracy in transcribing the spoken word of
participants to written texts (Hammersley, 2010). Transcription, however, has interpretive and
constructive elements where the transcriber influences how and what is transmitted to written
form (Lapadat & Lindsay, 1999; Tilley, 2003). In listening to spoken dialects of Arabic and
transcribing what I heard women say, I found it difficult to write some words in dialect form and
when written I could not re-read the words after a period of time. In these instances, I used
transliteration, which involves substituting the dialect form of a word with a MSA word of
conceptually equivalent meaning (Regmi, Naidoo, & Piklington, 2010). Accuracy of
transcription was enhanced in that both I and a research assistant helping with transcription were
from the Levant region and understood many of the cultural expressions, metaphors, and speech
connotations. Being both the interviewer and transcriber also allowed for better understanding of
the mood, context, and connotation behind a speech segment. Here, understanding involved an
interpretive element which meant the process of transcription was not only a technical activity.
In larger studies where the interviewer, researcher, and transcriber are different individuals, close
collaboration to ensure conceptual equivalence between spoken forms and written Arabic is
essential (Al-Amer, Ramjan, Glew, Darwish, & Salamonson, 2016).
Translating to preserve original voices. Following recommendations of other bilingual
researchers (Chen & Boore, 2009; Larkin, Dierckx de Casterlé, & Schotsmans, 2007; Nurjannah,
Mills, Park, & Usher, 2014; Santos, Black, & Sandelowski, 2015; Temple, 2006), I completed
the process of transcribing and preliminary data analysis in Arabic. My doctoral supervisor
checked two translated transcripts from early interviews to comment on the interview process,
use of probes, and initial concepts visible in the data. Themes and exemplars were translated by a
certified translator familiar with Arabic Levant dialects. The last step was blind back-translation
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of exemplar quotes into Arabic by an Arabic-English speaking research assistant to check for
equivalence of terminology and conceptual meaning (Figure 1).
Figure 1: Transcription and Translation Process.
Cross-language researchers have advocated for initial translation and coding to be done in
the original language of participants when a bilingual researcher is available, followed by
translation to the target language during the categorization phase, so as not to lose cultural
expressions and concepts. Chatti (2016) describes the differences between Arabic and English
using metaphors of colors, where the meaning of a phrase can be distorted or seem illogical
without defining a conceptual equivalence of meaning. The women in the study often used terms
that were difficult to translate into English due to varied conceptual meanings the words held in
different conversational contexts. For example, the word Al-ḥamdu lillāh (الَحْمد هلل) frequently
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stated throughout the interviews was often eliminated from final quote exemplars due to
difficulty explaining the varied meanings of the term. Al-ḥamdu lillāh translates to Praise be to
God: it serves as a personal reminder to be grateful, comforts a person in time of difficulty,
shows others the admired quality of patience, and is believed to elevate a Muslim’s spiritual
status when said often. The word can be used to show thankfulness for a good occurrence and it
can be used to convey a person’s patience and acceptance of God’s will around a negative
occurrence, or as a transition in a conversation to re-focus on the positive aspects of a difficulty:
Example 1: Now these evenings I sit alone….I have a little bit kind of depression. I am
alone. It is a little difficult. This is my life now, al-ḥamdu lillāh, I have very nice
children… (Participant 13)
Example 2: I said to him how many stents did you put. He said ‘three’ I said ‘really, how
blocked was it [referring to coronary arteries]’ He said ‘90% and the scan said between 60
and 70%, all the doctors are shocked that the first scan missed it’. Thank God it was not for
me to have a heart attack, so I always say al-ḥamdu lillāh God loves me and he does.
(Participant 7)
Example 3: I told you when I was sleeping at night I couldn’t breathe. So he [the doctor]
sent me to a cardiac specialist and a respiratory specialist, al-ḥamdu lillāh, I hope I am not
sick though. (Participant 1)
Transcription and analysis in Arabic meant avoiding problems of misinterpretation that
might occur with moving within various linguistic forms: colloquial Arabic, standard Arabic, and
English. The insider/outsider lens brought by my bilingual and bicultural status added a
dimension of complexity, where enhanced effort was needed to avoid making assumptions in the
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interpretive process. The study was small and I was engaged in both interviewing and conducting
data analysis which supported a more cohesive and reflective process. This approach, however,
would be time consuming and impractical for large data sets. This approach can also impact
negatively the collaborative process when members of a research team are not familiar with the
target language. To my knowledge there is no qualitative data analysis software that can
accommodate variations in Arabic dialects. This means in larger studies translation of transcripts
to English will be necessary to allow for management of large data sets. It might be useful to
select a sample of transcripts and conduct analysis in the original language, translate the same
transcripts to English and conduct analysis by a second independent researcher and then compare
analysis results across languages (Chen & Boore, 2009; Nurjannah, Mills, Park, & Usher, 2014).
This requires a collaborative effort in analysis and a discussion of discrepancies, but is a possible
way to trial enhancing rigor. This approach would also allow for better collaboration when some
members of the research team are not familiar with the original language (Santos, Black, &
Sandelowski, 2015).
Moving to Themes: Answering the Final Interpretive Question
Identifying patterns within context. An ID methodology relies on constant comparative
analysis processes, originating from grounded theory, to understand human phenomena (Thorne,
2016). In analyzing interview data, I became aware of the risk of misinterpreting contradictory
data, making erroneous inferences, and missing important data patterns. Attention to these risks
evolved from viewing myself and the women in the study as social actors bringing our beliefs,
assumptions, and agendas to the research encounter (Clandinn & Connelly, 2000; Yanos &
Hopper, 2008). This meant that data collected from the interview could not be viewed in
isolation of the inter-personal context of the interview encounter. Data contradictions relate to
178
differences within the data that are hard to explain. For example, the women in the study did not
criticize the healthcare system when directly asked for feedback but described a lack of access to
and utilization of health-promoting resources. I wondered if women were being respectful of my
registered nurse status or if the women were following the narrative of what ‘good immigrants
would say’ or whether they were truly grateful despite not having all their needs met. In
reflecting, I believe all three positions were true and the contradictions related to my perception
of the need for a single cohesive narrative. Making erroneous inferences relates to attributing
variations or similarities of data patterns to unrelated or secondary causes. Some women were
experiencing a life transition due to an unexpected alteration in health. Other women had lived
many years with personal health struggles. Women who had the time to emotionally and
mentally process the alteration in health were more likely to weave a positive storyline of
triumphs despite adversity. Women in transition struggled more with processing the impact of
the change and showed a lack of confidence about personal ability to manage health. It was
important to recognize that some variations in women’s experiences related to where women
were situated in their health journeys, versus differences in personal coping styles or external
socio-cultural influences. Missing important data patterns refers to an insider overlooking data
patterns that relate to shared experiences within the researched community. I was initially not
attuned to the relevance of transnational connections in shaping women’s lives until my doctoral
supervisor, a cultural outsider, drew my attention to this pattern in the data. As a bicultural
woman my life was built within transnational spaces, but I could not distance myself as a
researcher to identify the relevance to the phenomenon under study.
Attending to non-conforming data. Negative cases or exceptions that do not fit the data
patterns can allow for a more in-depth and complex understanding of study findings when the
179
lack of fit is explored closely (McPherson & Thorne, 2006). The dangers of thematic saturation
claims are higher with small studies where there might not be enough cases to generate a range
of variability in experiences (Morse, 1991). This study cannot claim to have reached thematic
saturation around the phenomenon of stroke prevention experiences in Arab immigrant women,
as evidenced by the emergence of experiences that suggest there is more out there to know about
the phenomenon of interest. For example, the woman in the sample with a university degree and
a career discussed difficulties with returning to work, and balancing career, family, and health
within a cultural context that values traditional female roles:
The event did happen [heart attack]. I had a hard time accepting it. It is like you let
everybody down. You feel guilt, like you did something wrong. People judge you because
you kill yourself working. They say you are running after money… It is not about the
money but satisfaction from work…it is hard for people to understand. (Participant 3)
The identification of role tension was not present in the accounts of other women who were less
educated and described themselves primarily as homemakers, wives, and mothers. Although this
woman shared many of the experiences of other women in the study, her experience of role
disruption might emerge as a thematic pattern with a larger sample of educated Arab women.
Another example relates to participation in physical activity. One of the women in the
study was actively engaged in exercise, going consistently to a female-only gym before and after
her stroke event. Her experiences helped elaborate the challenges women face with staying
physically active by demonstrating the prerequisites for successful engagement. She provided a
counter narrative of other women’s experiences with physical activity:
Participant: I know many ladies from the Arab community who stay at home, watch
television, and refuse when their children ask them to go to an exercise facility…I meet
180
more than one of their children, I meet them and they say I wish our mom was like you, I
wish she would go. I tell them to bring their moms. I swear if it wasn’t for my daughter
who signed me up for the gym I wouldn’t persist.
Interviewer: Tell me more about your persistence with exercise, not all people are like you,
it isn’t easy to keep at it.
Participant: Honestly, I am scared for myself, scared. If I have a headache when I go to
bed, I get worried about dying (laughs). Exercise keeps me in good shape.
Interviewer: You know it is good for your health so you continue with it.
Participant: Yes, I do not want to die because my sister, like I said before, had a stroke and
I do not want a stroke. (Participant12)
Non-conforming data, or data that does not fit the overall patterns of experience identified in the
study, can highlight areas that need further study or help enhance understanding of study themes.
The inability to always follow up on experiences that did not fit the overall data patterns was a
limitation of this study and resulted from difficulties with recruitment and time constraints.
Conclusion
For cross-cultural research to demonstrate rigor research processes must be culturally
relevant by serving the interests of the study population, contextual where the conditions of the
research process are factored into analysis, appropriate and flexible by attending to language and
communication processes, and respectful towards the cultures and traditions of research
participants (Im, Page, Lin, Tsai, & Cheng, 2004). I used interview strategies that balanced the
need to answer the research question with the needs of women to tell stories, express emotions,
and give advice. Translation and transcription were approached as interpretive processes that
were facilitated by being positioned as a bilingual and bicultural researcher. Finally, data
181
analysis required flexible and open approaches to attend to patterns in the data and interpret these
patterns within a broader social and cultural context. Ensuring rigor in cross-cultural research
was complicated by being a novice researcher who needed to learn the craft of doing good
qualitative research.
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